Chapter: 15: Accessing head and neck PrepU
A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?
"Hormones affect the severity of migraine headaches." explanation: Women's migraines are often longer in duration than men's, and women report chronic pain more often. These differences can be caused by menstruation, hormonal changes, pregnancy, and menopause (Migraine Research Foundation, 2020). Although people experience different symptoms with migraines, this is not the best response to the client's question. Migraine severity is not related to genetics.
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." explanation: Numbness, tingling, or loss of sensation in the toes are not normal age-related findings and should be assessed immediately. Older adults are more prone to having their blood pressure drop briefly upon standing. This drop in blood pressure may lead to dizziness and places the client at increased risk for falling. Older adults are often prescribed several medications and should be monitored for side effects such as muscle weakness. Vision changes such as a decline of accomodative ability are common in older adults and can also contribute to falls.
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." explanation: Numbness, tingling, or loss of sensation in the toes are not normal age-related findings and should be assessed immediately. Older adults are more prone to having their blood pressure drop briefly upon standing. This drop in blood pressure may lead to dizziness and places the client at increased risk for falling. Older adults are often prescribed several medications and should be monitored for side effects such as muscle weakness. Vision changes such as a decline of accomodative ability are common in older adults and can also contribute to falls.
A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention about the thyroid gland? Select all that apply.
- Largest endocrine gland in the body -Produces hormones that increase the metabolic rate of most body cells -Consists of two lateral lobes- Covered mostly by the sternomastoid muscles explanation:
A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply.
-Tachycardia -Diarrhea -Anxiety explanation: Hyperthyroidism may present as an emergency, with symptoms of hypermetabolism in all systems. The most common sign is tachycardia, but other possibilities include diarrhea, anxiety, fever, weakness, and even psychosis, coma, or death. Nurses should recognize clients at greatest risk for this emergency state. Such clients include those with thyroid tumors and those who have undergone thyroid surgery. Signs of hypermetabolism do not include bradycardia or headache.
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 explanation: The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.
Where is the temporal artery palpated?
Above the cheek bone near the scalp line explanation:
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?
Always use seat belts. explanation: The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations.
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 explanation: Arthritic changes in cervical spine 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 muscles
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?
Ask permission before palpating the head and neck explanation: Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.
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. explanation: Normally, lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. Lymph nodes greater than 6 inches (1.5 cm) in diameter is an abnormal finding and requires further assessment. If cancer metastasizes to the lymph nodes, they may enlarge but will not be painful. The nurse would further assess the client for other signs or symptoms before notifying the health care provider.
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. explanation: Normally, lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. Lymph nodes greater than 6 inches (1.5 cm) in diameter is an abnormal finding and requires further assessment. If cancer metastasizes to the lymph nodes, they may enlarge but will not be painful. The nurse would further assess the client for other signs or symptoms before notifying the health care provider.
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?
Ask the client to sip and swallow water. explanation: In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess the client regarding characteristics of the pain. explanation: : The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?
Assess the client's blood pressure. explanation: Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?
Assess the woman for hypothyroidism. explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.
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 explanation: While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.
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 explanation: 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 assessment is complete to obtain further orders. Reference:
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 explanation: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. A murmur is assessed during a cardiac assessment
The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?
C7 explanation: The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?
Consistency, delineation, mobility, tenderness explanation: Parameters of lymph node assessment include size, shape, delineation, mobility, consistency, and tenderness.
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?
Educating them about not drinking and driving explanation: Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these clients would not spend time with the teenagers teaching them how to turn the clients, fulfilling court requirements, or keeping the shelves restocked.
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic 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?
Graves' disease explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
What is the most common type of hyperthyroidism?
Graves' disease explanation: Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.
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 explanation: 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.
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone explanation: Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid explanation: The midline structures of the neck include (1) the mobile hyoid bone just below the mandible; (2) the thyroid cartilage, readily identified by the notch on the superior edge (larger in males than in females); (3) the cricoid cartilage; (4) the tracheal rings; and (5) the thyroid gland.
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?
Hypothyroidism explanation
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal inflammation explanation:Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.
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 explanation: Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
Notify the health care provider explanation: Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.
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. explanation: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.
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 explanation: The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few centimeters behind the tip of the mandible.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth explanation: 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.
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 conditions. 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 explanation: This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.
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 explanation: Earlobe asymmetry can be due to parotid gland enlargement caused by 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.
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
Perform a focused assessment explanation: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.
A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect?
Previous injuries to the head and neck explanation: Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for ne328xt?
Range of motion of the neck explanation: Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.
During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?
Recognize the weakened pulsation as an age-related change explanation: The nurse should consider the weakened pulse as an age-related change. The temporal arteries may have weak pulsation due to a decrease in the strength of the pulsation in old age. The nurse may check the blood pressure, but it is not the most appropriate action. The nurse may inform the physician, but the condition is not due to any underlying pathology. Decrease in the blood flow to the temporal artery will not affect the level of consciousness.
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
Stiff neck explanation: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?
Tension pneumothorax explanation: Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.
A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the following findings on assessment?
The temporal artery is hard, thick, and tender. explanation: An acute urgent condition is seen when the temporal artery is hard, thick, and tender with inflammation, as seen with temporal arteritis (inflammation of the temporal arteries that may lead to blindness). The temporal artery should be elastic and not tender. Sensitivity to light is not associated with temporal arteritis, but loss of vision may occur if not treated promptly. There is no asymmetry of the face with temporal arteritis.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply).
When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed? explanation: Asking the client when the lump was first noticed is included in the subjective data set in the onset section. Asking the client if alcohol has recently been consumed is included in the subjective data set in associated manifestations section. Asking the client whether the lump has changed is included in the subjective data set in the characteristic symptoms section. Assessing for familial experience with the client's chief complaint would be included in health history. The objective examination would provide the nurse with information regarding the experience of pain from the lump.
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 explanation: Acromegaly is characterized by enlargement of the facial features (nose, ears) and the hands and feet. Parkinson disease is caused by decreased dopamine manifests with rigidity, bradykinesia, postural instability (slow, jerky movements), cogwheel gait, shuffling, and mask-like facies. Cushing syndrome may present with a moon-shaped face, reddened face, and increased facial hair. Scleroderma is an autoimmune disorder that can cause changes in the skin, blood vessels, muscles, and internal organs; skin may be tight and hard on the face and hands.
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 explanation: The skull and facial bones are larger and thicker in acromegaly.
The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to
approach the client posteriorly. explanation: To palpate the thyroid, use a posterior approach. Stand behind the client and ask the client to lower the chin to the chest and turn the neck slightly to the right.
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
arthiritis explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
arthiritis explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?
characteristic symptoms explanation:Characteristic symptoms include having the client rate the level of pain as this provides information about the severity. This subjective information is categorized as a characteristic symptom. Information about anything else that the client may be experiencing during the headache (for example, nausea or blurred vision) should be documented in associated manifestations. Relieving factors provides information about anything that the client has attempted to relieve the symptoms. The location provides subjective information about where the headache is localized and pain radiates.
A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures?
consider cultural norms explanation: Cultural norms should always be considered when touching and assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head, or prohibit touching the feet before touching the head. Explaining U.S. norms and treating all clients the same despite culture is ethnocentrism; all cultures and their different norms must be respected. Following hospital policy does not have anything to do with cultural considerations unless there are limitations to cultural practices (for example, lighting candles).
The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?
flex the neck forward explanation: When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.
A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?
goiter explanation: The term used to describe an enlarged thyroid gland is goiter. A goiter may be seen in hyperthyroidism and hypothyroidism. Additional assessments will be required to determine the client's underlying condition causing the goiter, so it is not appropriate for the nurse to chart this finding as hyperthyroidism or hypothyroidism until further assessments are completed. Iodine deficiency is the primary cause of an enlarged thyroid gland, but such a deficiency has not yet been established, so it is not appropriate for the nurse to chart the finding as iodine deficiency.
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?
hyperthyroidism explanation:The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.
A nurse is about to receive a report on a 50-year-old female client diagnosed with Cushing syndrome. Which sign(s) and symptom(s) should the nurse expect? Select all that apply.
increased fat on the upper back increased facial hair round, puffy face thin extremities explanation:Cushing syndrome occurs when the adrenal cortex releases too much of the hormones cortisol, aldosterone, and sex hormones. This causes fluid and sodium retention (leading to a round, puffy face), potassium wasting, redistribution of fat (such as increased fat on the upper back, truncal obesity, and thin extremities), hyperglycemia, and hirsutism (deep voice and increased facial hair). Hypoglycemia is not associated with Cushing syndrome.
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?
malignancy explanation: Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile. In hypothyroidism, the thyroid gland may be enlarged, but discovering hard or fixed nodes warrants further assessment for malignancy.
A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache?
migraine explanation:Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light. A sinus headache is deep, constant, throbbing pain, with pressure-like pain in one specific area of face or head (e.g., behind eyes) and the face being tender to the touch. A cluster headache has stabbing pain and may be accompanied by tearing, eyelid drooping, reddened eye, or runny nose. A tension headache is dull, tight, and diffuse.
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an
parotid gland enlargement. explanation: Asymmetry in front of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?
preauricular explanation: The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?
red cheeks explanation: The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. A mask-like face is associated with Parkinson's disease. Swelling around the eyes is associated with nephrotic syndrome. An elongated prominent forehead is associated with acromegaly.
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
reduction of the blood supply to the brain. explanation: It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain.
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?
relieving factors explantion:
A nurse is preparing to perform a comprehensive assessment on a new client with a long history of Parkinson disease. Which sign(s) and symptom(s) should the nurse expect? Select all that apply.
rigidity shuffling gait tremors at rest expressionless face explanation: Due to a decreased amount of dopamine in the substantia nigra, which causes an increase in acetylcholine, a client with Parkinson disease will present with the following signs and symptoms: tremors at rest, rigidity, akinesia (or bradykinesia: slow movements), postural instability (shuffling, cogwheel gait), and an expressionless face (masked facies). These cardinal signs of Parkinson disease can be remembered by using the mnemonic TRAPI (tremors, rigidity, akinesia, and postural instability). Movements in clients with Parkinson disease are jerky and not smoot
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
sternomastoid explanation:
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension explanation: 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 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 explanation: This is a description of a typical tension headache.
A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders
tic douloureux explanation: Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas). Signs and symptoms of hyperthyroidism include goiter, increased heart rate and blood pressure, increased appetite, loss of weight, heat intolerance. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. A stroke may cause a facial droop that is not painful.
When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?
to observe the movement of the thyroid gland explanation: Although providing the client with water may help the client feel more at ease during the assessment and promote development of the nurse-client relationship, the significance of bringing a cup of water to into the assessment is to help observe the movement of the gland. As the client swallows, the nurse can visualize upward movement, contours, and symmetry of the thyroid. Dehydration can be a feature of hypothyroidism; however, the nurse is conducting the assessment, not providing supportive management or treatment.
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a
tumor related migraine explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)
• Shape of the lips • Shape of the nose shape of the eyes explanation: The most noticeable difference among racial groups is skin color. Shape of the eyes, nose, and lips also varies based on background and genetics. Variations in skull or neck shape or size relate more to height and weight than to specific racial or cultural background. Shape of the chin and ears is not related to cultural differences.