Chapter 10 The Head and Neck Prep U

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"

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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 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?

Arthritic changes of the cervical spine

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?

Ask permission before palpating the head and neck

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 Can cause the trachea to shift

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

Compressing the arteries bilaterally

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water So that they can swallow and the nurse is able to palpate each side of the gland

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

Cushings Syndrome

T/F Primary headaches are more worrisome than secondary headaches.

False

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? - Firearm Violence - Female Gender - Contact Sports - Transportation Accidents

Female Gender

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?

Hearing Acuity

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? - Constriction - Hypovolemia - Occlusion - Hypervolemia

Hypovalemia

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

What nursing diagnosis would be most appropriate for a client admitted with heart failure?

Ineffective tissue perfusion

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for.a source of the infection in the area that it drains

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess? - Sunken Face - Drooping of one side - Mask-like expression - asymmetry of earlobes

Mask-like expression

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

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?

Meningitis

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 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 is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

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

Open the mouth

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?

Parkinsons Disease

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 It does not provide meaningful data

A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

The nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply.

Rhinorrhea, ptosis, miosis, and lacrimation

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

Sternomastoid

Which of the following would the nurse document as an abnormal finding with lymph node assessment?

Tender Normal findings would be a size less than 1 cm, mobile, and discrete

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

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?

There is an infection in the area that these nodes drain

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?

Trigeminal Neuralgia

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

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

A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?

Assess the client regarding characteristics of the pain.

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? - increased size of a single thyroid nodule - A nonpalpable carotid pule - Decreased strength of temporal artery pulsations - Tenderness of lymph nodes on palpation

Decreased strength of temporal artery pulsations

What does the nurse assess the face for? (Select all that apply.) - Hair Color - Asymmetry - Affect - Edema - Involuntary Movements

Asymmetry, Edema, and involuntary movements