Wk 9- Head & Neck

The nurse is describing the process of palpating the lymph nodes with a student nurse. Which statement, if made by the nurse, is accurate?

"Use a gentle circular motion of the finger pads to feel the lymph nodes." The most effective way for palpating the lymph nodes is to use gentle circular motion of the finger pads. This helps in feeling the lymph nodes to assess their conditions. The dorsal surface of the hand is too big to palpate the lymph nodes. Moving the fingertips lightly over the skin is not an ideal process to palpate the lymph nodes. It would not be possible to palpate the lymph nodes with the thumb and the second finger.

The nurse is caring for a patient with epistaxis. Which symptom is most likely to be seen in this patient?

Bleeding from the anterior nasal septum Epistaxis is bleeding from the anterior nasal septum. It is rarely severe and can be easily controlled. Causes include nose picking, forceful coughing or sneezing, fracture, and coagulation disorder. Loss of the sense of smell is called anosmia. It is due to an inflammation of the nasal mucosa, blockage of nasal passages, or a destruction of one temporal lobe of the brain. Anosmia can be temporary or permanent. A hole in the septum is usually caused by snorting cocaine or methamphetamine. Chronic infection, trauma from continual picking of crusts, or nasal surgery may also result in perforated septum. Acute sinusitis may result in thick, creamy nasal drainage.

The nurse notices that a patient has a deviated nasal septum. What action should the nurse take when caring for this patient?

Chart the findings for future reference. A deviated nasal septum looks like a hump or shelf in one side of the nasal cavity. The nurse should document this finding for further reference. Although this is not a condition that must be fixed immediately, it may be useful information for the future if the patient ever requires nasal suctioning or insertion of a nasogastric tube during a hospital stay. The nurse does not need to inform the health care provider, because the finding is not significant. The nurse does not need to arrange supplementary oxygen unless the patient has an obstructed airflow. The nurse must not disregard the finding but should document it for future reference.

The nurse is assessing a patient who reports having lost the sense of smell. Which cranial nerve may be affected in this patient?

Cranial nerve I A patient with loss of smell may have an impaired cranial nerve I, which transmits the sense of smell to the temporal lobe of the brain. The olfactory receptors merge into the olfactory nerve, or cranial nerve I. Cranial nerve IX is the glossopharyngeal nerve, which senses pain, touch, and temperature. Cranial nerve X is the vagus nerve that controls the pharynx, larynx, esophagus, trachea, bronchi, some portion of the heart, and palate. Cranial nerve XII is the hypoglossal nerve that controls tongue movement.

Which cranial nerve injury may cause anosmia in the patient?

Cranial nerve I (olfactory nerve) Cranial nerve I, or the olfactory nerve, innervates the olfactory bulb and mediates the sense of smell. Therefore, olfactory nerve injury may cause anosmia, or loss of the sense of smell in the patient. Cranial nerve II, which is also known as the optic nerve, innervates the eye and mediates the sense of vision. Therefore, optic nerve damage may cause loss of vision in the patient. Cranial nerves III and IV, which are also known as the oculomotor and trochlear nerves, respectively, innervate the muscles that aid in the movement of the eyeball. Therefore, damage to them may result in ptosis, or drooping eyelids.

While assessing neurologic function, the nurse touches a cotton wisp on the patient's forehead, cheeks, and chin. Which cranial nerve is the nurse testing?

Cranial nerve V The nurse is testing the sensory function of cranial nerve V (or the trigeminal nerve). This is the largest cranial nerve and it performs sensory functions related to the nose, eyes, tongue, and teeth. This nerve is further divided into ophthalmic, maxillary, and mandibular branches. The patient's light touch sensation is tested by touching a cotton wisp to these designated areas while the patient's eyes are closed. Cranial nerve IV (or the trochlear nerve) is a motor nerve that is connected to the midbrain and controls the eye muscles and turning of the eye. Cranial nerve VI (or the abducens nerve) helps in the lateral movement of the eyes, and cranial nerve VII (or the facial nerve) is responsible for various facial expressions. Because all of these are motor nerves, the light touch sensation test is not required for these cranial nerves.

Which statement accurately describes the lymphatic system?

It eliminates foreign substances from the body. The lymphatic system is made of the lymph nodes and the lymph. It is a major part of the immune system, which detects and eliminates foreign substances from the body. The lymphatic system is a separate vessel system from the cardiovascular system. The nodes filter the lymph and engulf the pathogens, preventing harmful substances from entering the circulation. The lymph vessels gather the clear, watery fluid called lymph from the tissue spaces and drain into the circulation.

Which statement describes the function of the lymphatic system?

It filters the lymph to engulf bacteria. The lymphatic system is a separate vessel system from the cardiovascular system. Its main job is to detect and eliminate foreign substances from the body. The lymph nodes filter the lymph and engulf pathogens such as bacteria, thus preventing harmful substances from entering the circulation. The circulatory system helps in tissue oxygenation. Because the lymphatic system is not the part of the circulatory system, it does not collect pathogens directly from the blood. It is a major part of the immune system, but it is a characteristic of the lymphatic system and not a function.

The nurse is caring for a patient with dizziness. During the assessment, the patient says, "Please hold me; the room is spinning." Which condition would the nurse suspect?

Objective vertigo Labyrinthine-vestibular disorder in the inner ear is the main cause of vertigo. The patient with objective vertigo feels like the room is spinning. Presyncope is the state of fainting and lightheadedness. The patient states that he or she is going to faint in presyncope. The patient with disequilibrium has musculoskeletal disorder and feels that he or she is going to fall. The patient with subjective vertigo states that he or she has a spinning feeling.

What is the major function of the glossopharyngeal nerve?

Swallowing and gagging The glossopharyngeal nerve is cranial nerve IX. Its major motor function is to help in swallowing. The gag reflex, also known as a laryngeal spasm, is a reflex contraction of the back of the throat, evoked by touching the roof of the mouth, the back of the tongue, the area around the tonsils, and the back of the throat; the sensory limb of cranial nerve IX predominantly mediates this reflex. Lateral movement of the eye is controlled by the abducens nerve, or cranial nerve VI. The sensory part of the vagus nerve (cranial nerve X) contributes to the ability to taste. The hypoglossal nerve (cranial nerve XII) controls the muscular movement of the tongue.

What is the best description of the supraclavicular region?

The area at the sternomastoid muscle The supraclavicular region is the area at the sternomastoid muscle. The superficial cervical region refers to the area overlying the sternomastoid muscle. The deep cervical region indicates the area deep under the sternomastoid muscle. The area along the edge of the sternomastoid muscle does not indicate the supraclavicular region.

The nurse is assessing a patient who has an acute infection and enlarged lymph nodes. Which assessment finding would the nurse expect?

The lymph nodes are warm, tender, and firm, but freely movable. In case of acute infection, the lymph nodes are warm, tender, and firm, but are freely movable. Cancerous lymph nodes are hard, longer than 3 cm, nontender, and are fixed. Enlarged, firm, nontender, and mobile lymph nodes are seen in patients with human immunodeficiency virus infection. The lymph nodes are painless, rubbery, and discrete in patients with Hodgkin lymphoma.

The nurse is evaluating a student nurse who is palpating a patient's cervical lymph nodes. Which action, if performed by the student nurse, should be corrected by the nurse?

The student nurse uses strong pressure for assessing lymphatic glands. The student nurse should not use strong pressure for assessing the lymphatic glands, because strong pressure may push the nodes into the neck muscles. The submental gland is present under the tip of the chin and is easy to palpate with one hand. The student nurse should palpate the lymph nodes by using a circular motion of the finger pads for proper identification of the position and tenderness of the glands. The student nurse should follow the proper sequence of the lymph node assessment, because variation in sequence may increase the chances of missing some small nodes. Therefore, the student nurse should start assessing the parotid tenderness from the preauricular lymph nodes that are present in front of the ear.

Which nerve mediates facial sensations of pain and touch?

Trigeminal nerve Facial sensations of pain or touch are mediated by the trigeminal nerve; it is also known as cranial nerve V, and this nerve has three sensory branches. The spinal accessory nerve is cranial nerve XI and innervates the neck muscles; this nerve has no role in facial sensation. The trochlear nerve is cranial nerve IV; this motor nerve innervates a single muscle, which is the superior oblique muscle of the eye. The oculomotor nerve is cranial nerve III. It enters the orbit of the eye and controls most of the eye's movements.