Nurs 204 - Chapter 15: Head and Neck (2)

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

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? a. gurgle b. murmur c. bruit

Bruit

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

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. superficial to the sternomastoid b. in the midline, a few centimeters behind the tip of the mandible c. in front of the ear d. near the mandible

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

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? a. previous injuries to head and neck b. changes in sleep habits

Previous injuries to the head and neck

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

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

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? a. "Do you have difficulty swallowing?" b. "How long have you experienced discomfort from the lump?" c. "When did you first notice the lump?" d. "Is there more than one lump?"

a. "Do you have difficulty swallowing?

What is the most common type of hyperthyroidism? a. Grave's disease b. Moon face c. Thyroid cancer d. Cushing's disease

a. Graves disease

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

ask the client if touching the head is permissible.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? a. bell's palsy b. migraine headache c. tension headache d. temporal arteritis

b. Migraine headache

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

c. Above the cheek bone near the scalp line

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. shortness of breath b. range of motion of the arms and shoulders c. range of motion of the neck d. headache

c. range of motion of the neck

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. relieving factors d. treatment

c. relieving factors

A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the following findings on assessment? a. Sensitivity to light b. asymmetry of the face c. the temporal artery is elastic, red and tender d. the temporal artery is hard thick and tender

d. The temporal artery is hard, thick, and tender.

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