Ch. 14 Head, Face, Neck, and Regional Lymphatics

Cluster headaches

excruciating stabbing or burning sensations located in the eye, temple, forhead, or cheek Abrupt Onset: Peaks in minutes, lasts 45-90 minutes.

What two hormones does the thyroid produce?

triiodothyronine (T3) and thyroxine (T4)

Cranial Nerve IV

trochlear nerve, innervates superior oblique muscle of the eye.

Which medical diagnosis involves the excessive secretion of the growth hormone by the pituitary gland? Acromegaly Cushing syndrome Myxedema Graves disease

Acromegaly involves excessive secretion of the growth hormone by the pituitary gland.

Which findings would alert the nurse that a patient's lymph nodes may be cancerous? Select all that apply. Mobile Matted Hard Bilateral Nontender

Findings that would indicate a cancerous lymph node is cancerous include matted, hard, and nontender. Lymph nodes connect together and give a matted appearance in the patient with malignancy. Hard nodes indicate cancer. Nontender nodes indicate cancer. The nodes are not mobile in malignancy; they are fixed. Cancerous nodes are usually unilateral whereas infection causes bilateral changes.

Which medical diagnosis involves the increased production of thyroid hormone? Acromegaly Graves disease Myxedema Cushing syndrome

Graves disease (Hyperthyroidism) involves increased production of the thyroid hormone, causing an increased metabolic rate.

Cranial Nerve III

Occulomotor Nerve, enters the orbit of the eye and controls most of the eye's movements.

What abnormality presents as "masklike", with elevated eyebrows, staring gaze, oily skin, and drooling?

Parkinson's Syndrome deficiency of dopamine

Which assessment findings would be signs and symptoms of myxedema? Select all that apply. Fatigue Puffy face Weight loss Slow reflexes Excessive sweating

The signs and symptoms of myxedema include fatigue, puffy face, and slow reflexes. Myxedema occurs because of the deficiency of thyroid hormone. Weight loss and excessive sweating occur in Graves disease (hyperthyroidism).

Cranial Nerve XI

The spinal accessory nerve that innervates the sternocleidomastoid and trapezius.

Tension Headaches

Usually occur at times of stress; dull band of pain around the entire head (both sides). Gradual onset: lasts 30min to days

While auscultating the enlarged thyroid with the bell of a stethoscope, the nurse hears a soft, pulsatile blowing sound. Which term would the nurse use to describe this finding? Lymphadenopathy Normal Bruit Crepitation

A bruit is a soft, pulsatile blowing sound heard best with the bell of the stethoscope and is an abnormal finding over the trachea. A bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid gland (hyperthyroidism). Lymphadenopathy means enlargement of the lymph nodes from infection, allergy, or neoplasm. A bruit is not present normally. Crepitation is a crackling feeling a nurse can palpate over a damaged lung area or arthritic or injured joint.

A patient with acromegaly presents with coarse facial features. Which additional facial finding would the nurse monitor for? Facial paralysis on one side Elongated head Exophthalmos Moonlike face

A patient with acromegaly will have an elongated head. Excessive secretion of growth hormone from the pituitary gland after puberty results in acromegaly. This excessive secretion of growth hormone causes progressive enlargement of the head and coarse facial features. The patient with Bell palsy may have complete paralysis on one-half of the face and an inability to wrinkle the forehead and raise the eyebrows. Exophthalmos (bulging eyeballs) indicates hyperthyroidism or Graves disease, not acromegaly. A moonlike face is a sign of Cushing syndrome, not acromegaly.

In which body area would the nurse palpate to find a Virchow node? Submandibular Cervical Supraclavicular Occipital

A single enlarged, nontender, hard left supraclavicular node may indicate neoplasm in the thorax or abdomen (Virchow node). Nodes in the submandibular area often relate to inflammation or a neoplasm in the head and neck. Painless, rubbery nodes in the cervical region indicate Hodgkin lymphoma. Enlargement of the occipital node is common in patients with human immunodeficiency virus infection.

Which assessment finding would the nurse observe in a patient who has Bell palsy? Whistles Wrinkles forehead Raises eyebrows simultaneously Smiles showing teeth only on one side

Bell palsy causes paralysis of the muscles on one side of the face, causing only one side of the teeth to show while smiling. The patient may not be able to whistle because of the paralysis of one-half of the face. Because the patient has paralysis on one side, the patient cannot wrinkle the forehead or raise both eyebrows simultaneously.

Which abnormality is a result of cranial nerve VIII paralysis of facial muscles? Describe characterstics

Bells Palsy Complete paralysis of one-half (unilateral) of the face; can't wrinkle forehead, raise eyebrow, close eyelid, whistle, or show teeth on affected side. Pain behind ear, drooling, smooth forehead. *improved with corticosteroids and antivirals within 72h of onset.

What abnormality accompanies chronic wasting diseases such as cancer, dehydration, and starvation?

Cachetic Appearance Features include: sunken eyed, hollow cheeks; and exhausted, defeated expression.

Which parameter is the most important in evaluating neurologic deficit in a patient who has a concussion? Level of consciousness Pupil response Projectile vomiting Grip strength

Changing level of consciousness is most important in evaluating neurologic deficit because it can indicate early changes in brain trauma and increased intracranial pressure. Although pupil response is a component of neurologic assessment, it is not the most important. Although projectile vomiting can occur in increased intracranial pressure, it is not the most important. Grip strength can be unequal with neurologic problems, but it is not the most important.

Migraine Headaches

Commonly one sided but can be two, throbbing pulse pain. Rapid onset: peaks 1-2 hrs and lasts 4-72hrs. Pain is often behind the eyes.

Which medical diagnosis involves excessive secretion of adrenocorticotropin hormone (ACTH)? Myxedema Acromegaly Graves disease Cushing syndrome

Cushing syndrome involves excessive secretion of the adrenocorticotropin hormone. A moonlike face, hirsutism on the upper lip and chin, prominent jowls, and red cheeks are the clinical manifestations of Cushing syndrome.

Which finding is the cause of vertigo?

Disturbance in the inner ear or the sensory nerve pathway causes vertigo. Labyrinthine-vestibular disorder in the inner ear is the main cause of vertigo.

A patient has hypothyroidism and presents with fatigue. Which additional signs and symptoms would the nurse monitor for? Select all that apply. Dry, coarse hair Dry, cool skin Cold intolerance Muscle cramps Infrequent blinking

Dry, coarse hair; dry, cool skin; and cold intolerance are all signs and symptoms of hypothyroidism. The hair of a patient with hypothyroidism is dry and coarse. The skin of such patients is cool, dry, and puffy. Such patients cannot tolerate low temperature. Muscle cramps and infrequent blinking are signs and symptoms of hyperthyroidism, not hypothyroidism.

Which question would the nurse ask the patient to determine the presence of dysphagia? "When was your last alcoholic drink?" "How easy is it to move your joints?" "Are you dizzy when walking?" "Do you have any difficulty swallowing?"

Dysphagia is difficulty swallowing, so the nurse would ask, "Do you have any difficulty swallowing?" Asking about the last alcoholic drink can alert the nurse to possible alcohol withdrawal, not dysphagia. Asking about how easy it is to move joints reflects range of motion limitations. If the patient is dizzy when walking, that could indicate disequilibrium, not dysphagia.

Which cranial nerve mediates facial sensations of pain and touch? Spinal accessory Trochlear Trigeminal Oculomotor

Facial sensations of pain or touch are mediated by the trigeminal nerve; it is also known as cranial nerve V, and this nerve has three sensory branches. The spinal accessory nerve is cranial nerve XI; it innervates the neck muscles and has no role in facial sensation. The trochlear nerve is cranial nerve IV; this motor nerve innervates a single muscle, which is the superior oblique muscle of the eye. The oculomotor nerve is cranial nerve III. It enters the orbit of the eye and controls most of the eye's movements.

Which assessment findings would the nurse expect when palpating the lymph nodes of a patient with an acute infection? Select all that apply. Enlarged Matted Nontender Warm Freely movable Rubbery

Lymph nodes are enlarged, warm, and freely movable in an acute infection. Matted lymph nodes are usually cancerous. Normal lymph nodes are nontender; lymph nodes are tender during an infection. The presence of rubbery lymph nodes without pain may indicate Hodgkin lymphoma in the patient; lymph nodes are firm during an infection.

Which medical diagnosis involves the deficiency of thyroid hormone? Acromegaly Myxedema Graves disease Cushing syndrome

Myxedema (Hypothyroidism) involves the deficiency of thyroid hormone. symptoms: fatigue, cold intolerance, puffy everything (periorbital edema).

Which symptoms would be found in a patient with migraine headaches? Select all that apply. Agitation Nausea A warning aura Pain lasting for 72 hours Pain worsening with heat exposure

Nausea, a warning aura, and pain lasting for 72 hours are all symptoms of a migraine headache. Such patients feel nausea and have an urge to vomit. A patient with migraine headaches experiences visual changes such as blind spots or flashes of light. This is called an aura. Migraine headaches can last for 72 hours or more. A patient with a cluster headache has a feeling of agitation; such pain is exacerbated with exposure to heat.

Which assessment finding is typical in a patient who has the mumps?

Parotid gland enlargement

Which history finding would be typical for a patient with a single thyroid cancerous nodule? Is a male Has a 2-centimeter nodule Had childhood radiation exposure Is negative for previous goiter

Patients with a history of radiation exposure, especially in childhood, are at increased risk for thyroid cancer. Females are more at risk than males for thyroid cancer. Nodule size greater than 4 centimeters (cm)—not a 2-cm size—is typical of thyroid cancer. Patients with a history of goiter or nodules are at increased risk for thyroid cancer. A negative history indicates the patient has no history of goiter.

The nurse would expect to hear which statement from a patient with presyncope? "Please hold me; I'm spinning." "Please help me; I'm going to fall." "Please let me sit because I may faint." "Please let me leave; this room is spinning."

Patients with presyncope state that they are going to faint. Lightheaded, swimmind sensation or feeling of fainting or falling caused by decreased blood flow to brain or heart.

The nurse would expect to hear which statement from a patient with Vertigo? sub or obj... "Please hold me; I'm spinning." "Please help me; I'm going to fall." "Please let me sit because I may faint." "Please let me leave; this room is spinning."

Patients with subjective vertigo (not disequilibrium) state that they have a spinning feeling.

Which signs and symptoms would the nurse find while assessing a patient with Graves disease (hyperthyroidism)? Select all that apply. Tachycardia Weight loss Bulging eyeballs Periorbital edema Cold intolerance

Tachycardia, weight loss, and bulging eyeballs are signs and symptoms of Graves disease. Forceful tachycardia is seen in patients with hyperthyroidism. Weight loss is a typical sign of hyperthyroidism. Hyperthyroidism (Graves disease) is manifested by the patient's eyeballs bulging out; this condition is termed exophthalmos. Periorbital edema or swelling around the eyes is a sign of hypothyroidism. Cold intolerance is also seen in hypothyroidism. Therefore these symptoms are unlikely to be found in a patient with hyperthyroidism.

Which cranial nerve would the nurse be testing when asking the male patient to shrug his shoulders against resistance? V VII VIII XI

Test muscle strength and the status of cranial nerve XI by trying to resist the person's movements with the nurse's hands as the person shrugs the shoulders and turns the head to each side. Cranial nerve XI innervates the sternomastoid muscle of the neck. Therefore the nurse is testing cranial nerve XI. Cranial nerves V, VII, and VIII do not innervate neck muscles. Facial sensations of pain or touch are mediated by the 3 sensory branches of cranial nerve V, the trigeminal nerve. Cranial nerve VII innervates the facial muscles. Injury to cranial nerve VII may result in Bell palsy. Injury to cranial nerve VIII may give rise to the sensation of spinning and dizziness.

Which cranial nerve damage would cause the patient to have an asymmetric grin?

The facial muscles enable the formation of the facial expressions, and cranial nerve VII mediates the activity of these facial muscles.

Which bones are components of the patient's cranium? Select all that apply. Parietal Zygomatic Occipital Temporal Frontal

The four bones of the cranium are parietal, occipital, temporal, and frontal. The skull is a rigid bony box that protects the brain and the special sense organs. The skull is made of the bones of the cranium and the face. The zygomatic bone is a facial bone, not a cranial bone.

Which information would the nurse include in a teaching session about the primary function of the lymphatic system? It helps in tissue oxygenation. It collects pathogens from the blood. It filters the lymph to engulf bacteria. It is a part of the immune system.

The lymphatic system's main job is to slowly filter the lymph and engulf pathogens, preventing harmful substances from entering the circulation.

Which body parts would the nurse assess to determine functioning of the patient's thyroid gland? Select all that apply. Eye Ear Skin Hair Nose

The nurse would assess the eye, skin, and hair of patients to determine the functioning of the thyroid gland. A change in the secretion of hormones from the thyroid gland may affect various body systems. In the case of hypothyroidism, periorbital edema may be seen. Infrequent blinking is often associated with hyperthyroidism. Therefore assessment of the eyes is important. The skin of a patient with hyperthyroidism becomes warm and moist. The hair of such patients also becomes thin and silky. A patient with hypothyroidism will have cool, dry skin and dry, coarse hair. In no way does hypothyroidism or hyperthyroidism influence the auditory or olfactory system. The nurse does not need to assess the functionality of the ear or the nose.

Which action would the nurse take when assessing lymph nodes? Palpate the submental gland with two hands Use strong pressure to feel lymphatic glands Use a circular motion of the finger pads to feel nodes Palpate by starting with the posterior auricular lymph nodes

The nurse would palpate the lymph nodes by using a circular motion of the finger pads for proper identification of the position and tenderness of the glands. The submental gland is present under the tip of the chin and is easy to palpate with one hand, not with both hands. The nurse would not use strong pressure for assessing the lymphatic glands, because strong pressure may push the nodes into the neck muscles. The nurse would follow the proper sequence of the lymph node assessment, because variation in sequence may increase the chances of missing some small nodes. Therefore the nurse would start assessing from the preauricular lymph nodes (not the posterior auricular) that are present in front of the ear.

The nurse observes that the patient has an edematous face and myxedema. Which substance level would the nurse check in the patient's laboratory reports? Dopamine Growth hormone Adrenocorticotropin Thyroxine

The patient has an edematous face and myxedema, so the level of thyroxine (T 4, a thyroid hormone) would be checked. A decrease in thyroid hormone levels may lead to myxedema. A deficiency of dopamine leads to Parkinson syndrome, not myxedema. An excessive secretion of growth hormone leads to acromegaly, not myxedema. With excessive secretion of adrenocorticotropin hormone, Cushing syndrome may develop, not myxedema.

Which type of pain description would the nurse expect to hear from a patient who has a tension headache? "It feels like a vise is gripping my head." "This is so excruciating, I can't stand it." "My head feels like it is burning." "The throbbing feeling won't go away."

The patient who has a tension headache has pain that is viselike (vise is gripping my head). Excruciating and/or burning pain is characteristic of a cluster headache, not a tension headache. A patient with a migraine is more likely to feel throbbing pain than viselike tightness around the head.

In which area of the patient's body is the pain of a migraine headache likely located? Around the cheeks At the occipital region Across the back of the head Behind the eyes

The patient with a migraine headache may feel pain behind the eyes. Cluster headaches involve pain in the area around the cheeks. Headaches caused by stress and tension may occur at the occipital region or at the back of the head.

The nurse would expect to hear which statement from a patient with disequilibrium? "Please hold me; I'm spinning." "Please help me; I'm going to fall." "Please let me sit because I may faint." "Please let me leave; this room is spinning."

The patient with disequilibrium feels that he or she is going to fall. Shakiness or instability while walking occurs because of musculoskeletal disorders and indicates disequilibrium.

The nurse would expect to hear which statement from a patient with Vertigo? sub or obj... "Please hold me; I'm spinning." "Please help me; I'm going to fall." "Please let me sit because I may faint." "Please let me leave; this room is spinning."

The patient with objective vertigo (not disequilibrium) feels as if the room is spinning.

Which explanation by the nurse describes the supraclavicular region in relation to the patient's sternomastoid muscle? Area at the muscle Area overlying the muscle Located deep under the muscle Located along the muscle's edge

The supraclavicular region is the area at the sternomastoid muscle. The superficial cervical region refers to the area overlying the sternomastoid muscle. The deep cervical region indicates the area deep under the sternomastoid muscle. The area along the edge of the sternomastoid muscle does not indicate the supraclavicular region.

Which artery would the nurse palpate for on the patient's face?

The temporal artery can be palpated on the face and lies superior to the temporalis muscle.

Which information accurately describes the thyroid gland? It is in the chest. It has three lobes. It has a rich blood supply. It gathers lymphatic fluid.

The thyroid gland is an important endocrine gland with a rich blood supply. The gland straddles the trachea in the middle of the neck, not the chest. The gland has two lobes (not three), both conical in shape. The lymphatic system gathers lymphatic fluid; the thyroid synthesizes and secretes thyroxine and triiodothyronine hormones that stimulate the rate of cellular metabolism. The thyroid does not gather lymphatic fluid.

Which assessment finding would the nurse observe in a patient with atelectasis in the left lung lobe? Trachea shifts to the right. Trachea is pulled to the left. There is a tracheal tug. There is no tracheal movement.

The trachea will pull to the left. The trachea is pulled toward the affected side in the patient with atelectasis. Tracheal shift occurs because of unequal intrathoracic pressure within the chest cavity. The trachea is pushed to the unaffected side in the cases of tumor, pneumothorax, and aortic aneurysm. A tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. A normal trachea stays midline and is not pulled in either direction.

Cranial Nerve V

The trigeminal nerve, which is responsible for innervating the muscles of mastication.

Which instruction would the nurse include in the activity plan of a patient who had a concussion 24 hours ago? Using a stationary bike is recommended. It is best to stay on complete physical rest. Noncontact training drills can be started. Playing in the game tonight is safe.

Twenty-four (24) hours after a concussion, light aerobic exercise (walking, swimming, stationary bike) is recommended. Complete physical and brain rest is recommended for the first 24 hours after a concussion. Noncontact training drills are started 48 to 72 hours after the concussion. The patient should not play in a game 24 hours after a concussion; this does not allow the brain time to heal, especially in younger children.

Which signs and symptoms are associated with a head injury? Select all that apply. Vision changes Staggered walk Discharge from the ears Shortness of breath Morgan lines

Vision changes, staggered walk, and discharge from the ears are signs and symptoms associated with a head injury. Changes in vision such as double vision can be associated with head injury. The patient may exhibit a tremor or may stagger while walking. Bloody or watery discharge may also occur from the ear or nose. Shortness of breath is an associated symptom of a patient experiencing dizziness or a patient with hyperthyroidism. Morgan lines, a double or single crease on the lower eyelids, occur in children with allergies.