Chapter 15: Assessing Head and Neck

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 w/ malignancy

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 the pathophysiologic cause for this finding is related to what disease process?

Atelectasis

A nurse is assessing a client w/ hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the HCP?

Fixed to underlying tissue

A client presents to the health care clinic w/ reports of a stiff neck for the past 3 days. What objective info can the nurse obtain during the health history using inspection?

Head position

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine Headache (located around eyes, temples, cheeks and forehead; tension HA usually presents w/ stress, anxiety, or tension and is located in the frontal, temporal or occipital region)

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds

A nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

On the medial border of the mandible (tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle; occipital nodes can be palpated at the posterior base of the skull bone and submental lymph nodes can be palpated a few cm behind tip of mandible)

A client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional info should the nurse collect?

Previous injuries to the head and the neck

During the physical examination of a 60 year old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?

Recognize the weakened pulsation as an age-related change

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 (chronic infections cause nodes to become confluent; metastatic nodes enlarge and become fixed in place and nontender)

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate the bell over the lateral lobes

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition?

Bells palsy (trigeminal neuralgia causes shooting piercing facial pains over 5th cranial nerve; preauricular adenitis is characterized by tenderness and swelling of lymph nodes in front of ears)

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head toward the side being examined (stand behind client and ask him to lower the chin and turn the head towards the side being examined)

A client presents to the ER w/ reports of neck pain and a sudden onset of HA. Upon examination, the nurse finds that the client has an increased temp. and neck stiffness. The nurse recognizes these findings as most likely to be cause by what condition?

Meningeal inflammation (manifests as sudden HA, neck pain w/ stiffness, and fever)

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

Open the mouth

Upon inspection of a client w/ reports of fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition?

Parotid enlargement