NURS 267: Ch. 12
List the signs and symptoms of hyperthyroidism
-Hyper-metabolism -Tachycardia -Diarrhea -Anxiety -Fever -Weakness -Psychosis -Coma
Thickening of the skin, subcutaneous tissue, and facial bones and coarsening of facial features
Acromegaly
Refer patient to physical therapy
Activity intolerance
Paralysis, usually unilateral, of the facial nerve (CN VII); can be transient or permanent
Bell palsy
The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The patient was not wearing a helmet. When assessing the patient's head and neck, the nurse should prioritize the assessment for which of the following?
Bleeding
may be present with hyperthyroidism or thyrotoxicosis.
Bruit
A "brain attack"
Cerebral vascular accident
Assess characteristics
Chronic Pain
include activity intolerance, fatigue, chronic pain, and knowledge deficit.
Common nursing diagnoses for the head and neck
include pain, limited neck movement, lumps or masses, hypothyroidism, and hyperthyroidism.
Common symptoms of the head and neck
A patient presents with a complaint of drooping of his eyes, cheeks, and mouth on one side. This finding is most likely associated with pathology of which cranial nerve?
Cranial nerve V
Excessive production of exogenous ACTH results in a round "moon" facie, fat deposits at the nape of the neck, "buffalo hump", and sometimes a velvety discoloration around the neck (acanthosis nigra).
Cushing syndrome
While assessing the skin of a 24-year-old patient, the nurse notes decreased skin turgor. The nurse should further assess for signs and symptoms of
Dehydration
A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding
While examining the patient's neck, the nurse finds the trachea midline but has difficulty palpating the thyroid. What action would the nurse take next?
Document this finding as normal
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?
Enlargement of a node may be a sign of pathology that is distant from that node
Gather data to help determine if cause is physiologic or psychological
Fatigue
Physical examination of a patient reveals an enlarged tonsillar node. Acutely infected nodes would be
Firm but movable and tender
Enlarged thyroid gland; can be associated with hyperthyroidism, hypothyroidism, or normal thyroid function.
Goiter
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
Patients with severe headaches may be unable to provide a complete __________, but a focused __________ examination looking for neurologic changes is an essential nursing behavior.
History; physical
While reviewing laboratory values for thyroid function on an adult patient, the nures sees that the TSH is elevated, and the T3 and T4 are decreased. The nurse recognizes that these findings are indicative of
Hypothyroidism
In a patient with a neck injury, it is essential to keep the spine ________ to prevent spinal cord injury, and devices should not be removed until the spine is __________ of injury.
Immobilized; clear
Provide information in a variety of different forms
Knowledge Deficit
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?
Meningitis
Supraclavicular nodes
Metastatic cancer
In addition to chest pain, patients experiencing a ______________ may present with neck pain- so any patient with sudden onset of neck or jaw pain should be evaluated.
Myocardial Infarction
With severe hypothyroidism, patients present with periorbital swelling and edema of the face, hands, and feet
Myxedema
sternocleidomastoid muscle, thyroid gland, and aortic isthmus
Neck muscles that we inspect
Posterior auricle nodes
Otitis media
A mask-like facial appearance, rigid muscles, diminished reflexes, and a shuffling gait
Parkinson disease
Anterior cervical nodes
Pharyngitis
Which of the following best describes the instructions the nurse should give a patient when assessing the thyroid from the posterior approach
Please tilt you head slightly down and to one side
The lymph nodes that lie in front of the mastoid bone are the:
Pre auricular nodes
Patients with acute head injuries and neurologic changes must be ___________ and __________ assessed by the health care team.
Quickly and accurately
While assessing a patient, the nurse finds a palpable lymph node in the left supraclavicular region. Which of the following should be the next action?
Recognize that it is not common to palpate lymph nodes in this region and they must be carefully evaluated
Skin is firm and loses mobility, seemingly fixed to underlying tissues
Scleroderma
Which of the following descriptions is most consistent with a patient who has hypothyroidism?
Slightly obese female with a periorbital edema and a flat facial expression, who complains of constipation, deceased appetite, and fatigue
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
Stiff neck
also include the trachea, thyroid, and lymphatics
Structures of the head and neck
The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are symptoms of a cancerous lymph node?
The node is fixed and rubbery
normally smooth, rubbery, and moveable; common for it to be . nonpalpable
The thyroid
The nurse can best evaluate the strength of the sternocleidomastoid muscle by having the patient
Turn his or her head against resistance
include head or neck injuries, neck pain (may be cardiac), enlarged hard lymph nodes (which may indicate cancer), and thyrotoxicosis.
Urgent situations that need emergency assessment and intervention
Posterior cervical nodes
mononucleosis