Chapter 15 Assessing Head & Neck Prep U

A nurse assesses a young adult client who lost consciousness after a head-to-head collision while playing football. Which question should the nurse ask in order to determine characteristic symptoms of the head trauma? "Do you have a history of seizures?" "Are you feeling dizzy?" "How long were you unconscious?" "Do you feel like vomiting?"

"Do you have a history of seizures?" Seizures can be a precursor to or result of head trauma. This data provides more information about the severity of the head trauma; therefore, it is categorized within characteristic symptoms of the subjective data section of the assessment. Asking about dizziness or vomiting would be captured within the associated manifestations section of the subjective data set of the assessment. Asking about the length of time the client was unconscious is captured within the duration section of the subjective data set.

While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next? "How long have you experienced discomfort from the lump?" "When did you first notice the lump?" "Do you have difficulty swallowing? "Is there more than one lump?"

"Do you have difficulty swallowing? To assess manifestations associated with the lump in the neck, the nurse would ask if the client has difficulty swallowing. Asking how long the client has experienced discomfort from the lump is associated with duration. Asking when the client first noticed the lump assesses the onset of the lump. Asking if there is there more than one lump assesses the location of the lump.

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 man who has sought care for treatment of his episodic headaches that occur several times each day A woman who complains of recurrent headaches near the end of her workday spent at a computer station 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 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.

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 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 client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? a.Work with medical team to evaluate possible surgery. b.Assess the client regarding characteristics of the pain. c.Educate the client regarding cervical spine pain. d.Discuss pharmacologic interventions.

Assess the client regarding characteristics of the pain.

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.It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.

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 Hypothyroidism Nephrotic syndrome A tumor

Grave's disease 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 Thyroid cancer Cushing's syndrome Moon face

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.

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. stand upright in front of the nurse. lie in a supine position. lie in a side-lying position.

Have the client remain seated upright. Then palpate the lymph nodes with your finger pads in a slow walking, gentle, circular motion.

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? I will take my thyroid hormone replacement medication once every week. I must keep my follow up appointments to receive my thyroid hormone injections. I must take thyroid hormone replacement medication for the rest of my life. I will complete the entire course of thyroid hormone replacement over six weeks.

I must take thyroid hormone replacement medication for the rest of my life. After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? Feeling anxious Laboratory tests Increased heart rate Increased blood pressure

In order to determine the presence of hypothyroidism, laboratory tests to determine blood levels of the TSH, FT4 and FT1 are needed to ensure correct diagnosis of this condition. The presence of tachycardia, increased blood pressure and anxiety are signs associated with hyperthyroidism.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

In the midline, a few centimeters behind the tip of the mandible

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. 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.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Sit without moving Sit upright Open the mouth Perform a chewing action

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.

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? a.Encourage the use of safety equipment b.Encourage the client to take a safety course c.Teach proper posture, bending, and lifting d.Encourage proper nutrition to promote healing

a.Encourage the use of safety equipment 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.

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? a.Look for a source such as infection in the area that it drains b.Assess for meningitis c.Assess for dietary changes d.Look for involvement of other regions of the body

a.Look for a source such as infection in the area that it drains 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 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? a.Migraine b.Cluster c.Tension d.Analgesic rebound

a.Migraine This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.) a.Physical examination for neurologic changes b.Scheduling a computerized tomography (CT) scan c.Scheduling a magnetic resonance imaging (MRI) scan d.Scheduling an electroencephalography (EEG) e.Conducting a focused history interview

a.Physical examination for neurologic changes e.Conducting a focused history interview A client with severe headaches may be unable to provide a complete history, but a focused history and physical examination looking for neurologic changes are critical nursing interventions. Nursing interventions do not include scheduling MRIs, CT scans, or EEGs without a prescription.

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? a.There is an infection in the area that these nodes drain. b.There is an inflammatory response in the musculature of the boy's neck. c.The tissue underlying the nodes is infected. d.The boy requires assessment of his thyroid gland.

a.There is an infection in the area that these nodes drain. 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.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first a.ask the client if touching the head is permissible. b.explain to the client why the assessment is necessary. c.determine whether the client desires a family member present. d.examine the lymph nodes of the neck before examining the head.

a.ask the client if touching the head is permissible. 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.

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? a.characteristic symptoms b.relieving factors c.associated manifestations d.location

a.characteristic symptoms 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.

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

acute infection The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.

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? Stress Arthritis Meningeal inflammation Injury to the sternomastoid

arthritis 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.

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? Bronchitis Endocarditis Tuberculosis Atelectasis

atelectasis

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: a.inhale deeply. b.swallow a small sip of water. c.flex the neck to each side. d.cough deeply.

b. swallow a small sip of water Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.

Where is the temporal artery palpated? a.Just left of midline at the base of the neck b.Above the cheek bone near the scalp line c.Between the mandibular joint and the base of the ear d.Just left or right of the spine at the base of the skull

b.Above the cheek bone near the scalp line The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? a.I must keep my follow up appointments to receive my thyroid hormone injections. b.I must take thyroid hormone replacement medication for the rest of my life. c.I will complete the entire course of thyroid hormone replacement over six weeks. d.I will take my thyroid hormone replacement medication once every week.

b.I must take thyroid hormone replacement medication for the rest of my life. After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to a.stand upright in front of the nurse. b.sit in an upright position. c.lie in a side-lying position. d.lie in a supine position.

b.sit in an upright position. Have the client remain seated upright. Then palpate the lymph nodes with your finger pads in a slow walking, gentle, circular motion.

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? a.Masseter b.Sternocleidomastoid c.Temporalis d.Trapezius

b.sternocleidomastoid

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? a.The underlying vascular network b.The underlying bones c.Noted anatomists d.Their anatomical positions

b.the underlying bones Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

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 a.Cushing syndrome. b.parotid gland enlargement. c.acromegaly. d.Paget disease.

c. acromegaly. The skull and facial bones are larger and thicker in acromegaly.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? a.Discuss pharmacologic interventions. b.Educate the client regarding cervical spine pain. c.Assess the client regarding characteristics of the pain. d.Work with medical team to evaluate possible surgery.

c.Assess the client regarding characteristics of the pain. 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.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? a.In front of the ear b.At the angle of the mandible c.In the midline, a few centimeters behind the tip of the mandible d.Superficial to the sternomastoid

c.In the midline, a few centimeters behind the tip of the mandible

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? a.Hashimoto thyroiditis b.thyroid cyst c.hyperthyroidism d.benign tumor

c.hyperthyroidism 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 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 a.tumor-related headaches. b.cluster headaches. c.tension headaches. d.migraine headaches.

c.tension headaches Tension headaches are dull, tight, and diffuse.

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? a.Myxedema b.Bell's palsy c.Scleroderma d.Cushing's syndrome

d.Cushing's syndrome 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 nigracans). The scenario does not describe signs and symptoms demonstrated by a client with myxedema, scleroderma, or Bell's palsy.

Teenagers doing community service following arrest for driving under the influence 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? a.Keeping the shelves restocked b.Teaching them how to turn these clients every 2 hours c.Fulfilling the court requirements d.Educating them about not drinking and driving

d.Educating them about not drinking and driving

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? a.Brain tumor b.Effects of age-related changes c.Hyperthyroidism d.Hypothyroidism

d.Hypothyroidism 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.

A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate? a.Benign b.Cluster c.Tension d.Migraine

d.Migraine A throbbing, severe, unilateral headache that lasts 6 to 24 hours and is associated with photophobia, nausea, and vomiting suggests migraine. The scenario does not indicate tension, cluster, or benign headaches.

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment? a.Earlobe placement b.Temporomandibular joint c.Preauricular nodes d.Nasolabial folds

d.Nasolabial folds The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that cannot be inspected as they are very small. Earlobe placement is not an appropriate method to determine facial symmetry.

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? a.Myxedema b.Cushing's syndrome c.Nephrotic syndrome d.Parkinson's disease

d.Parkinson's disease 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.

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? a.Avoid risky activities such as snowboarding b.Use of guns should be supervised by an adult c.Wear nonslip shoes in the house. d.Always use seat belts.

d.always use seat belts

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? a.location b.onset c.treatment d.relieving factors

d.relieving factors 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.

What activity is known to aggravate a tension headache? Driving Listening to music Exercise Prolonged sleep

driving

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 next? a.Range of motion of the arms and b.shoulders c.Shortness of breath d.Headache e.Range of motion of the neck

e.range of motion of neck 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.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? Round and 8 mm in size Soft in consistency Fixed to underlying tissue Mobile from side to side

fixed to underlying tissue

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what? Height and weight Cultural background Ethnic background Gender

height and weight Variations in cranium or neck shape or size relate more to height and weight than to specific racial or cultural background.

What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple

hyoid bone

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?

impending stroke 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 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 a. clustered headache b.tension headache c.migraine headache d. tumor related headache

migraine headache

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? Administer intravenous pain medication. Prepare the client for a temporal artery biopsy. Notify the healthcare provider immediately. Palpate the carotid pulses bilaterally at the same time.

notify health care provider immediately

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called?

prodrome Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Is there an aura with neurologic symptoms, such as change in vision or numbness or weakness in an arm or leg?

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 next? Range of motion of the arms and shoulders Headache Range of motion of the neck Shortness of breath

range of motion of the neck

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? a.Pain that is temporary b.Stiff neck c.Pain without new d.symptomatology e.Pain centered behind the eyes

stiff neck Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.

A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action? Ask client about medications taken for arthritis. Review the client's history for recent closed head injury. Teach neck exercises to be done daily. Suggest referral to orthopedic spine specialist.

suggest referral

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

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

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

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

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 tension headache. cluster headache. migraine headache. tumor-related headache.

tumor related headache Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.