chapter 10 head and neck

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

"Do you have any visual changes before the headache?"

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?

Assess the woman for hypothyroidism.

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

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 pathophysiological cause for this finding is related to what disease process?

Atelectasis

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?

Auscultation

A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?

C7

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

Cup of water

When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?

Cushing's syndrome

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?

Decreased strength of temporal artery pulsations

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

Meningeal inflammation

Which of the following would the nurse consider to be an urgent situation?

New onset chest pain

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.

The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following?

Radiation therapy has been linked to the development of thyroid cancer.

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?

The notch on its superior edge

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

Trigeminal neuralgia

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?

bruit

Anterior triangle of the neck

front upper portion of the side.

A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?

migraine

A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?

percussion

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

tension headaches

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

underlying bones