Chapter 15: Assessing Head and Neck & Chapter 18
A client's nasal mucosa is pale reddish-blue. What should the nurse ask the client to validate this finding? "How often do you inhale substances?" "How long have you had a head cold?" "When did you have surgery on your nose?" "Do you sneeze a lot when around fresh cut grass or pollen?"
"Do you sneeze a lot when around fresh cut grass or pollen?" Explanation: In allergic rhinitis the nasal mucosa may be pale blue or red. A perforated septum is associated with inhaled substances. Thick discolored mucus or gross pus is seen with an infection. Absence of normal structures suggests previous nasal surgery.
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?
4+ Explanation: The nurse should document the tonsillar grading as 4+ because the tonsils are so large that they are touching one another. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are barely visible. Tonsils that touch the uvula are graded 3+.
A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? Hopelessness Acute Pain Ineffective Health Maintenance Self-Care Deficit
Acute Pain Explanation: The nursing diagnosis of Acute Pain can be confirmed because it meets the major defining characteristic of verbalization of sore throat. Impaired swallowing is not related to impaired neurologic or neuromuscular function. There is no criterion to confirm that this client cannot maintain health maintenance because this is an acute problem. No data exist to confirm the nursing diagnoses of Self-Care Deficit or Hopelessness.
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 Bacterial thyroiditis Cranial damage Muscle tension
Arthritic changes of the cervical spine Explanation: 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 muscles
A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? Weak gait Dysphagia Right ptosis Facial weakness
Dysphagia Explanation: Dysphagia can lead to aspiration and is the priority concern to maintain a patent airway. A weak gait can lead to falls but is not priority over airway. Right ptosis, or eyelid drooping,and facial weakness can inhibit certain facial movements but this is not a priority concern over airway.
During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
Either side of the frenulum on the floor of the mouth Explanation: The nurse should inspect the Wharton's ducts on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right side of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate sites to inspect for salivary ducts.
A client diagnosed with Sjogren syndrome should be given which instructions?
Eye drops and sucking on hard candy may used to relieve dryness.
What is the most common type of hyperthyroidism?
Graves' disease
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the patient's lips and surrounding skin. The nurse would document this finding as being:
Herpes simplex Explanation: The herpes simplex virus produces recurrent vesicular eruptions of the lips and surrounding skin. Angular cheilitis is the presence of fissures at the edges of the mouth. Actinic cheilitis affects the lower lip and is characterized by scales, thickening, and eversion of the lip tissue. Angioedema is a diffuse swelling of the dermis and subcutaneous tissue.
You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? Hoarseness Dyspnea Dysphagia Alopecia
Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
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 patient has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?
Hypothyroidism Explanation: Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client? Diabetes Brain tumor Impending stroke Hyperthyroidism
Impending stroke Explanation: A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.
A patient comes to the clinic and reports nosebleeds. What area of the nose is thebleeding most likely coming from?
Kiesselbach plexus Explanation: The most common site of nasal bleeding is the Kiesselbach plexus on the anterior septum.
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? Migraine headache Meningeal inflammation Trigeminal neuralgia Parkinson's disease
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 nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient? Migraine Meningitis Cervical fracture Measles
Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated
Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?
Nasolabial folds
The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?
Overuse of nasal spray may cause rebound congestion.
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
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 is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the...
area underneath the tongue.
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 thyroid cyst Hashimoto thyroiditis benign tumor
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.
The rich blood supply of the nose serves to...
warm the inspired air. Explanation: The rich blood supply of the nose warms the inspired air as it is moistened by the mucous membrane.
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.
A client diagnosed with Sjogren syndrome should be given which instructions? Eye drops and sucking on hard candy may used to relieve dryness. Blood pressure should be checked frequently. Condom use can reduce the risk of transmission. Taking mucus thinning medication can relieve symptoms.
Eye drops and sucking on hard candy may used to relieve dryness. Explanation: Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness. Sjogren syndrome does not affect blood pressure. Sjogren syndrome is not contagious or sexually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness.
An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? Kiesselbach plexus Rosenmuller fossa Columella Ala
Kiesselbach plexus Explanation: Kiesselbach plexus is the most common site of epistaxis. Rosenmuller fossa is the most common site of nasopharyngeal cancer. The midline columella divides the oval nares (nostrils), which are openings that lead into the internal nose and are lined with the skin and the ciliated mucosa. The anterior slope of the nose is the dorsum, which ends inferiorly at the tip and laterally at the ala.
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia Explanation: Leukoplakia is white patches inside of the mouth. Gingivitis is inflamed gums that bleed. Small red spots occur with petechiae. Fordyce granules are while or yellow papules appearing on the cheeks, tongue and lips.
A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Sitting with the head erect and at the eye level of the nurse Tilting the head backwards, with the neck flexed Semi-recumbent position, with the chin lifted Prone, with arms relaxed at the sides
Sitting with the head erect and at the eye level of the nurse
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 This could be a sign of pneumothorax This could be a sign of an embolus This could be a sign of a parotid stone
This could be a sign of cancer Explanation: 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.
The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.) X VIII VII IX XII
VII IX XII Explanation: The autonomic nervous system and cranial nerves VII (facial) and IX (glossopharyngeal) innervate secretions of the major and minor salivary ducts. Cranial nerve XII (hypoglossal) innervates the submandibular glands. Cranial nerves VIII and X are not involved.
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
Vitamin B12 deficiency Explanation: The tongue and buccal mucosa may appear smoother and shiny from papillary atrophy and thinning of the buccal mucosa. This condition is called smooth glossy tongue and may result from deficiencies of riboflavin, folic acid, and vitamin B 12.
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to lie in a supine position. lie in a side-lying position. stand upright in front of the nurse. sit in an upright position.
sit in an upright position. Explanation: Have the client remain seated upright. Then palpate the lymph nodes with your finger-pads in a slow walking, gentle, circular motion.
An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are...
touching each other. Explanation: 4+ Tonsils touch each other.
An older adult client reports lacking the desire to eat. The client also reports having discomfort from dentures and a persistently dry mouth. Which questions should the nurse include when taking the health history for this client? "When was your last dental examination?" "Can you tell me what you eat in a day?" "How much water do you drink in a day?" "Which medications do you take?" "Have you noticed any bluish-black swelling under your tongue?"
"When was your last dental examination?" "Can you tell me what you eat in a day?" "How much water do you drink in a day?" "Which medications do you take?" Explanation: It is important, especially for older adults who wear dentures, to have a dental examination at least once per year to prevent oral damage from an ill-fitting apparatus. Diet and hydration can play a major role in the production of saliva and its flow in the mouth. Identifying nutrition and hydration problems can assist the nurse in planning care and client education. A large variety of medications cause dry mouth. This problem would be exacerbated if the client was taking multiple medications with dry mouth as a side effect. Asking about the medications can help the nurse determine the cause of the dryness. Asking about bluish-black swelling under the tongue assesses for varicose veins in the mouth. These are unrelated to dry mouth and ill-fitting dentures. Varicose veins of the tongue are not clinically significant and would not prevent the client from being able to eat.
When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: Cancers often occur. Sloughing of papillae begins. Early jaundice can be detected. Lesions from loose dentures are found.
Cancers often occur. Explanation: It is important to inspect the sides and undersurface of the tongue and the floor of the mouth, because these are areas where cancer most often develops.
During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding? Diphtheria Candidiasis Torus palatinus Kaposi sarcoma
Candidiasis Explanation: Thrush or candidiasis is a yeast infection on the palate, although it may appear elsewhere in the mouth. It is characterized by thick, white plaques that are somewhat adherent to the underlying mucosa. In diphtheria, the throat is dull red, and a gray exudate is present on the uvula, pharynx, and tongue. A torus palatinus is a midline bony growth in the hard palate that is fairly common in adults. Its size and lobulation vary. The lesions of Kaposi sarcoma are deep purple. The lesions may be raised or flat.
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? Migraine Cluster Tension Stress
Cluster Explanation: Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
Cranial nerve XII (hypoglossal)
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 Explanation: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigra). The scenario does not describe signs and symptoms demonstrated by a patient with myxedema, scleroderma, or Bell's palsy.
A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal? Fatigue, cold intolerance, and constipation. Weight loss, rapid pulse, heat intolerance. Palpitations, limp hair, and sweating. Muscle weakness, increased metabolic rate, and anxiety.
Fatigue, cold intolerance, and constipation. Explanation: The client's lab values are consistent with hypothyroidism. Fatigue, cold intolerance, constipation, depression, anorexia, dry skin, brittle and coarse hair, menstrual irregularities, and weight gain are all symptoms of hypothyroidism. All other symptoms in the answer options are indicative of hyperthyroidism.
A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client? Scrape off the white coating with a toothbrush. Clean mouth and tongue with hydrogen peroxide and water. Rinse mouth with antifungal medication as prescribed. Apply the prescribed topical antibiotic gel as directed.
Rinse mouth with anti-fungal medication as prescribed. Explanation: The client's symptoms are consistent with oral candiasis which is common in clients taking antibiotics. The tongue will become further irritated if attempts are made to completely scrape off the coating or if the mouth is rinsed with peroxide. Since this condition is commonly caused by antibiotic use, then another antibiotic for the tongue would not be prescribed.
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.
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. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.
A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect? Diphtheria Kaposi's sarcoma Torus palatinus Thrush
Thrush Explanation: Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate
The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?
Vitamin deficiency Explanation: A smooth and often sore tongue that has lost its papillae, sometimes just in patches, suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron. Candidiasis or white patches would be on the tongue if a yeast infection is present. The tongue may have black areas if antibiotics were recently used. The tongue would deviate from the midline if CN XII is damaged.
The submandibular glands open under the tongue through openings called...
Wharton ducts. Explanation: The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through openings called Wharton's ducts.
A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? acute bacterial sinusitis allergic rhinitis rhinitis medicamentosa epistaxis
acute bacterial sinusitis Explanation: Acute bacterial sinusitis should be suspect if there is a recent history of upper respiratory tract infection. The sensitivity for the symptom correlation of upper respiratory tract infections is 90%, and the specificity is 80%. Headache and tenderness on palpation of the sinuses are also features acute bacterial sinusitis. Allergic rhinitis is not associated with an infectious process. Nasal congestion that results from triggering allergens, usually environmental, is the cause. Rhinitis medicamentosa results from excessive use of decongestants used to treat a nonbacterial nasal congestion. Epistaxis is a condition that occurs when the mucosa of the nares is eroded and exposed vessels break leading to what is commonly called a nosebleed. Tenderness and headache are not associated features of epistaxis.
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. Explanation: Tension headaches are dull, tight, and diffuse.
