PrepU Chapter 15 Head and Neck
The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening? Rush Gurgle Murmur Bruit
Bruit
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 Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder
Previous injuries to the head and neck Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.
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 parotid gland enlargement. acromegaly. Paget disease. Cushing syndrome.
acromegaly
Where is the anterior triangle located?
in front of sternomastoid muscle
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? Sternocleidomastoid Trapezius Masseter Temporalis
The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).
Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.) Shape of the ears Shape of the chin Shape of the lips Shape of the nose Shape of the eyes
nose, lips, eyes
A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery Discuss pharmacologic interventions Chronic pain related to cervical spine injury Assess characteristics
Assess characteristics 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. Option C represents a nursing diagnosis, not an intervention.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? Assess the client's blood pressure. Provide medication for pain relief. Inquire about family history of headaches. Review the client's medical record.
Assess the client's blood pressure. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
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? Endocarditis Bronchitis Atelectasis Tuberculosis
Atelectasis Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.
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 V Cranial nerve VI Cranial nerve VII Cranial nerve VIII
Cranial nerve VII Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.
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 Refer the patient to the primary care provider promptly Perform a focused endocrine assessment Position the patient supine and reattempt palpation
Document this as an expected assessment finding It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
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? Encourage the use of safety equipment Encourage proper nutrition to promote healing Encourage the client to take a safety course Teach proper posture, bending, and lifting
Encourage the use of safety equipment
Primary headaches are more worrisome than secondary headaches. True False
False
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out? A tumour Hypothyroidism Graves' disease Nephrotic syndrome
Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
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.
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 Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder
Previous injuries to the head and neck Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.
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? Teach neck exercises to be done daily. Ask client about medications taken for arthritis. Review the client's history for recent closed head injury. Suggest referral to orthopedic spine specialist.
Suggest referral to orthopedic spine specialist. Pain, numbness, or tingling may indicate compression of spinal root nerves, requiring further evaluation, preferably by a spine specialist. Limited range of motion with pain is most indicative of arthritis, not spinal nerve root compression. Neck exercises do not relieve nerve compression; the client needs further evaluation first. Signs of head injury include changes in level of consciousness and orientation and behavior changes.
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? Tension pneumothorax Cardiac tamponade Flail chest Severe neck fracture
Tension pneumothorax Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.
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 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 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 explain to the client why the assessment is necessary. ask the client if touching the head is permissible. determine whether the client desires a family member present. examine the lymph nodes of the neck before examining the head.
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 client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing? scleroderma hypothyroidism hyperthyroidism Cushing's syndrome
hypothyroidism Manifestations of hypothyroidism include an edematous face, hands, and legs. Manifestations of scleroderma include a hardening face with thinning facial skin. Manifestations of hyperthyroidism include warm, smooth, moist skin and exophthalmos. Manifestations of Cushing's syndrome include a moon-shaped face with reddened cheeks and increased facial hair.
