Chapter 10: The Head and Neck
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? "Standing up slowly is important because dizziness can cause falls." "Loss of senss of sensation in the toes is an age-related change." "Certain medications can cause muscle weakness." "Changes in vision such as decreased accommodation happen with aging."sation in the toes is an age-related change." "Certain medications can cause muscle weakness." "Changes in vision such as decreased accommodation happen with aging."
"Loss of sensation in the toes is an age-related change."
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? Correct response:
"Loss of sensation in the toes is an age-related change."
A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?
"Most head and neck cancers are linked to smoking."
A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. -lethargy -constipation -cool skin -lower systolic blood pressure -weight loss
-lethargy -constipation -cool skin -lower systolic blood pressure
A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?
2
The nurse notes that a client's right lobe of the thyroid gland is larger than the left. What should the nurse consider as being the reason for this finding?
A normal finding
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? Audible referred breath sounds at the site of the thyroid An audible S3 sound at the site of the thyroid A sound of turbulent blood flow in the thyroid Irregular S1 and S2 rhythms in the thyroid
A sound of turbulent blood flow in the thyroid
Which of the following clients is most likely to be diagnosed with migraine headaches? A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room A woman who complains of recurrent headaches near the end of her workday spent at a computer station A man who has sought care for treatment of his episodic headaches that occur several times each day A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
Where is the temporal artery palpated? Above the cheek bone near the scalp line Just left of midline at the base of the neck Between the mandibular joint and the base of the ear Just left or right of the spine at the base of the skull
Above the cheek bone near the scalp line
A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?
Acromegaly
A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? Avoid asking the client to remove her clothes for the examination Have a nurse who is the same sex as the client perform the examination Ask permission before palpating the head and neck Palpate the client's feet before palpating the head
Ask permission before palpating the head and neck
A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse?
Ask the client if they have experienced any other signs or symptoms
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
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance
Attempting to roll the structure up and down and side to side
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?
Attempting to roll the structure up and down and side to side.
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 the bell over the lateral lobes.
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Immediately notify the health care provider Document the findings in the nurse notes Auscultate with the bell over the lateral lobes Ask the client about past history of hypothyroidism
Auscultate with the bell over the lateral lobes
At which location would a nurse palpate a client's submental lymph nodes?
Behind the tip of the mandible
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?
Bruit
A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?
Cluster
When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs? Myxedema Cushing's syndrome Scleroderma Bell's palsy
Cushing's syndrome
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
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines? "Do they occur after you have been tense or anxious?" "When you consume alcohol, do you get a headache?" "Do you have any eye symptoms, such as tearing?" "Do you have any visual changes before the headache?"
Do you have any visual changes before the headache?"
A client describes their frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?
Do you have any visual changes before the headache?"
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?
Enlargement of a node may be a sign of pathology that is distant from that node.
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?
Female gender
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following? Firearm violence Female gender Contact sports Transportation accidents
Female gender
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?
Graves' disease
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding? A tumor Hypothyroidism Graves' disease Nephrotic syndrome
Graves' disease
What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer
Graves' disease
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone
What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple
Hyoid bone
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? Select all that apply. Sternocleidomastoid muscle Hyoid bone Cricoid cartilage Carotid artery Esophagus
Hyoid bone Cricoid cartilage
A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect? Effects of age-related changes Brain tumor Hyperthyroidism Hypothyroidism
Hypothyroidism
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?
Loss of sensation in the toes is an age-related change."
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? "Standing up slowly is important because dizziness can cause falls." "Loss of sensation in the toes is an age-related change." "Certain medications can cause muscle weakness." "Changes in vision such as decreased accommodation happen with aging."
Loss of sensation in the toes is an age-related change."
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
Mask-like expression
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?
Meningitis
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? Migraine Meningitis Cervical fracture Measles
Meningitis
A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache? Tension Migraine Cluster Analgesic rebound
Migraine
A client reports a right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes which condition is likely to produce these symptoms?
Migraine headache
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Temporal arteritis Migraine headache
Migraine headache
Which of the following would the nurse consider to be an urgent situation?
New onset chest pain
An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding? Nodes feel matted together on palpation Nodes are delimited on palpation Nodes appear grown together on palpation Nodes are demarcated on palpation
Nodes are delimited on palpation
A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?
Notify the health care provider.
A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is the priority of the nurse?
Notify the health care provider.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately.
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action? Notify the healthcare provider immediately. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately.
A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?
On the medial border of the mandible
During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?
Pain radiating from eye to temporal region.
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical condition. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?
Parkinson's disease
Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
RC: Cushing's syndrome
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?
Referral for further assessment of thyroid function
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral? Referral for further assessment of thyroid function Referral for assessment of cranial nerve function Referral for assessment of lymphatic system function Referral for further assessment of swallowing ability
Referral for further assessment of thyroid function
The nurse in a community health clinic is preparing to assess the thyroid gland of a 22-year-old female client. Complete the table by selecting which action to take for each step of the thyroid assessment process.
Step of the Assessment - Action to Take Position self to complete the assessment -Stand behind the client Identify landmarks by palpation-Identify thyroid and cricoid cartilages and thyroid isthmus Displace the thyroid gland for palpation -Ask the client to swallow
A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding? Correct response:
Tender
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
Tension
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis? Tension Migraine Cluster Analgesic rebound
Tension
What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.) The sternomastoid The mandible The midline of the neck The omohyoid muscle The clavicle
The sternomastoid The mandible The midline of the neck
The nurse is assessing a client's thyroid by having the client swallow a small sip of water. What will the nurse document as an expected finding?
The thyroid cartilage and cricoid cartilage move upward symmetrically.
The nurse is assessing a client's thyroid by having the client swallow a small sip of water. What will the nurse document as an expected finding? The thyroid cartilage and cricoid cartilage move upward symmetrically. The right side of the thyroid cartilage moves up higher than the left. The thyroid appears larger on the left side of the neck. The client states that swallowing during the exam is difficult.
The thyroid cartilage and cricoid cartilage move upward symmetrically.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? Noted anatomists The underlying bones Their anatomical positions The underlying vascular network
The underlying bones
The palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding? The boy requires assessment of his thyroid gland. There is an inflammatory response in the musculature of the boy's neck. The tissue underlying the nodes is infected. There is an infection in the area that these nodes drain.
There is an infection in the area that these nodes drain.
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? Cluster headache Tension headache Migraine headache Trigeminal neuralgia
Trigeminal neuralgia
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of a metastasis tonsillitis nasopharyngitis a goiter
a metastasis
A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?
acromegaly
A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate? Parkinson disease Cushing syndrome scleroderma acromegaly
acromegaly
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for
acromegaly.
The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?
anterior triangle of a client's neck.
A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?
cerebrovascular accident
A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders? Bell palsy temporal arteritis trigeminal neuralgia cerebrovascular accident
cerebrovascular accident
A client is experiencing pain around the eye that radiates to the face and temporal area. Which image diagrams this client's pain?
eye
A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a migraine headache. cluster headache. tension headache. tumor-related headache.
migraine headache
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to
sit in an upright position.
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to
swallow a small sip of water.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? cluster tension migraine hypertensive
tension
A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of
tension headaches.
While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible.
trigeminal neuralgia.
