Prep U-Chapter 15-2

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

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

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?

Arthritis

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?

Atelectasis

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

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

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

Cranial nerve VII (7)

What is the most common type of hyperthyroidism?

Graves disease

A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states that she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data?

Health Seeking Behaviors

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

Impaired comfort related to possible neck injury

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

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

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

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

The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?

The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid muscle and medial to the midline of the neck

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

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

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