Prep U flashcards Chapter 10

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

Percussion "When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data."

Secondary headaches are more worrisome than primary t/f

true

The face has how many bones?

14

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial Nerve VII

A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?

Trigeminal Neuralgia- Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

metastasis

Which of the following would the nurse suspect if assessment reveals a skull and facial bones that are larger and thicker than normal?

Acromegaly "Acorn-shaped enlarged skull bones are seen in Paget's disease. Brain tumor and Parkinson's disease would not change the shape, size, or configuration of the skull"

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations "The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age."

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

Head position While collecting history, the nurse would be able to inspect the client to see in what position the head was being held. Range of motion would require the nurse to give the client commands and would be performed during the physical assessment. Neck tenderness and thyroid size would require the use of palpation, not inspection, and would also be covered in the physical assessment portion of the examination.

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify?

Hyoid bone, cricoid cartilage

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?

Stiff Neck

The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?

The submandibular glands are located inferior to the mandible underneath the base of the tongue. - The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer- Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

Which of the following would put the client at risk for falls? Select all that apply. dizziness, hypotension, confusion, palpitations, diaphoresis

confusion, dizziness, hypotension

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

A sound of turbulent blood flow in the thyroid "A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical."

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

Atelectasis- lung collapse "Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift."

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral lobes- "If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once the assessment is complete to obtain further orders."

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement?

Headache Impact Test- "The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint."

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?

Hypovolemia- A weak pulse can indicate hypovolemia, shock or decreased cardiac output. Pulse inequality may indicate a constriction or occlusion. Hypervolemia would be manifested by bounding pulses.

A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?

Posterior cervical

Hypothyroidism in the older adult can be difficult to diagnose. What are some of the reasons it is difficult to diagnose? Select all that apply.

Subtle onset Symptoms attributed to the aging process Chronic diseases

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension- Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

Arthritic changes of the cervical spine- "Arthritic changes in cervical spine may may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscle"

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth- "While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate."

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?

Parotid enlargement Earlobe asymmetry can be due to parotid gland enlargement. In this case, the client may have mumps as parotid enlargement is accompanied by fever. It can also be due to an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.

The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound?

Pulmonic "The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to the sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum."