CH 15 Head/Neck PrepU

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) - Coffee drinker - Female gender - Male gender - Tobacco use - Age older than 50 years

- Male gender - Tobacco use - Age older than 50 years

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? A. Always use seat belts. B. Use of guns should be supervised by an adult. C. Wear nonslip shoes in the house. D. Avoid risky activities such as snowboarding.

A. Always use seat belts.

A nurse is preparing to examine a client from Southeast Asia who has been experiencing chronic headaches. Which of the following should the nurse do in light of this client's cultural background? A. Ask permission before palpating the head and neck B. Palpate the client's feet before palpating the head C. Avoid asking the client to remove her clothes for the examination D. Have a nurse who is the same sex as the client perform the examination

A. Ask permission before palpating the head and neck

A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse? A. Ask the client if they have experienced any other signs or symptoms. B. Notify the health care provider. C. Ask the client if they have a history of cancer. D. Document findings as normal.

A. Ask the client if they have experienced any other signs or symptoms.

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Assess the client regarding characteristics of the pain. B. Work with medical team to evaluate possible surgery. C. Educate the client regarding cervical spine pain. D. Discuss pharmacologic interventions.

A. Assess the client regarding characteristics of the pain.

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. Bruit B. Rush C. Murmur D. Gurgle

A. Bruit

Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers? A. Educating them about not drinking and driving B. Teaching them how to turn these clients every 2 hours C. Keeping the shelves restocked D. Fulfilling the court requirements

A. Educating them about not drinking and driving

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition? A. Meningeal inflammation B. Migraine headache C. Parkinson's disease D. Trigeminal neuralgia

A. Meningeal inflammation

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? A. The underlying bones B. The underlying vascular network C. Their anatomical positions D. Noted anatomists

A. The underlying bones

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? A. This could be a sign of cancer B. This could be a sign of an embolus C. This could be a sign of pneumothorax D. This could be a sign of a parotid stone

A. This could be a sign of cancer

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: A. acromegaly. B. Cushing syndrome. C. parotid gland enlargement. D. Paget disease.

A. acromegaly.

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders? A. cerebrovascular accident B. temporal arteritis C. Bell palsy D. trigeminal neuralgia

A. cerebrovascular accident

While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should: A. refer the client to a physician for further evaluation. B. palpate the cricoid cartilage for smoothness. C. ask the client to flex his neck to the left side. D. observe whether the client has difficulty swallowing water.

A. refer the client to a physician for further evaluation.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A. tension B. migraine C. cluster D. hypertensive

A. tension

Where is the temporal artery palpated? A. Just left of midline at the base of the neck B. Above the cheek bone near the scalp line C. Between the mandibular joint and the base of the ear D. Just left or right of the spine at the base of the skull

B. Above the cheek bone near the scalp line

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? A. Bacterial thyroiditis B. Arthritic changes of the cervical spine C. Muscle tension D. Cranial damage

B. Arthritic changes of the cervical spine

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? A. Injury to the sternomastoid B. Arthritis C. Meningeal inflammation D. Stress

B. Arthritis

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? A. Encourage the client to take a safety course B. Encourage the use of safety equipment C. Encourage proper nutrition to promote healing D. Teach proper posture, bending, and lifting

B. Encourage the use of safety equipment

A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement? A. Auscultation B. Headache Impact Test C. Family health history questionnaire D. A mnemonic assessment tool

B. Headache Impact Test

A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms? A. Nephrotic syndrome B. Parkinson's disease C. Myxedema D. Cushing's syndrome

B. Parkinson's disease

The nurse is caring for a client who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node? A. The node matches the node on the opposite side of the body. B. The node is fixed and rubbery. C. The node is less than 1 cm in size and feels boggy. D. The node is soft and moves freely.

B. The node is fixed and rubbery.

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate? A. Parkinson disease B. acromegaly C. scleroderma D. Cushing syndrome

B. acromegaly

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse? A. "Changes in vision such as decreased accommodation happen with aging." B. "Certain medications can cause muscle weakness." C. "Loss of sensation in the toes is an age-related change." D. "Standing up slowly is important because dizziness can cause falls."

C. "Loss of sensation in the toes is an age-related change."

A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements? A. "Alcohol plays a very little role in head and neck cancers." B. "Asbestosis does not cause head and neck cancers." C. "Most head and neck cancers are linked to smoking." D. "Chewing tobacco does not cause cancer."

C. "Most head and neck cancers are linked to smoking."

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Educate the client regarding cervical spine pain. B. Work with medical team to evaluate possible surgery. C. Assess the client regarding characteristics of the pain. D. Discuss pharmacologic interventions.

C. Assess the client regarding characteristics of the pain.

What is the most common type of hyperthyroidism? A. Moon face B. Cushing's syndrome C. Graves' disease D. Thyroid cancer

C. Graves' disease

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? A. Measles B. Migraine C. Meningitis D. Cervical fracture

C. Meningitis

A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse? A. Continue to monitor the client. B. Document the findings. C. Notify the health care provider. D. Administer acetaminophen for the pain.

C. Notify the health care provider.

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? A. Palpate the carotid pulses bilaterally at the same time. B. Administer intravenous pain medication. C. Notify the healthcare provider immediately. D. Prepare the client for a temporal artery biopsy.

C. Notify the healthcare provider immediately.

A client arrives at the emergency room reporting drooping of one side of their face since early in the morning. The client denies pain and the face is asymmetrical with a left-sided droop. No other deficiencies such as weakness of the extremities or a change in gait are observed. What action should the nurse take? A. Request a stat computed tomography scan to rule out a stroke. B. Alert the rapid response team. C. Request a neurology consult to determine the cause of facial muscle weakness. D. Discharge the client home because there are no other symptoms.

C. Request a neurology consult to determine the cause of facial muscle weakness.

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? A. Trapezius B. Temporalis C. Sternocleidomastoid D. Masseter

C. Sternocleidomastoid

The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention? A. This is a sign of hyperthyroidism B. This is a sign of hypothyroidism C. The client could be experiencing a stroke D. The client could be suffering from dehydration

C. The client could be experiencing a stroke

The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head? A. tilt the head back B. turn the head towards the right shoulder C. flex the neck forward D. turn the head towards the left shoulder

C. flex the neck forward

A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding? A. hypothyroidism B. hyperthyroidism C. goiter D. iodine deficiency

C. goiter

A client reports having a headache. The nurse performs a specialized focused assessment and notes the following: client rates pain 10 on a scale of 1 to 10 (10 being the worst), nauseated and vomited, reporting sensitivity to noise and light. The nurse determines that the client is most likely experiencing which of the following types of headache? A. tension B. cluster C. migraine D. sinus

C. migraine

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to: A. flex the neck to each side. B. cough deeply. C. swallow a small sip of water. D. inhale deeply.

C. swallow a small sip of water.

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of A. tumor-related headaches. B. cluster headaches. C. tension headaches. D. migraine headaches.

C. tension headaches.

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which of the following conditions should the nurse additionally assess for, based on this finding? A. Unilateral vision B. Paget's disease C. Neurologic disorder D. Aortic insufficiency

D. Aortic insufficiency

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? A. Endocarditis B. Tuberculosis C. Bronchitis D. Atelectasis

D. Atelectasis

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae? A. C5 B. C1 C. C3 D. C7

D. C7

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? A. Brain tumor B. Diabetes C. Hyperthyroidism D. Impending stroke

D. Impending stroke

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. At the angle of the mandible B. Superficial to the sternomastoid C. In front of the ear D. In the midline, a few centimeters behind the tip of the mandible

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

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. Tension headache B. Temporal arteritis C. Bell's palsy D. Migraine headache

D. Migraine headache

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. Stiffness in the right shoulder B. Difficulty with swallowing C. Changes in sleeping habits D. Previous injuries to the head and neck

D. 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? A. There is an inflammatory response in the musculature of the boy's neck. B. The boy requires assessment of his thyroid gland. C. The tissue underlying the nodes is infected. D. There is an infection in the area that these nodes drain.

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

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? A. Hashimoto thyroiditis B. benign tumor C. thyroid cyst D. hyperthyroidism

D. hyperthyroidism

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. onset B. treatment C. location D. relieving factors

D. relieving factors

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

The triangle in front of the sternocleidomastoid muscle that is inside the sloped triangle