Chapter 15: Assessing Head and Neck

A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?

"Hormones affect the severity of migraine headaches."

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?

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

A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.)

1. Physical examination for neurologic changes 2. Conducting a focused history interview

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

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 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?

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?

Assess the client regarding characteristics of the pain.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

Assess the client's blood pressure.

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

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 with the bell over the lateral lobes

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

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular

A nurse is providing care for a client who experienced a head injury and who just moved to the United States from Southeast Asia. What cultural nursing consideration should the nurse take into account when performing an assessment on clients from different cultures?

Consider cultural norms.

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?

Educating them about not drinking and driving

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

Fixed to underlying tissue

What is the most common type of hyperthyroidism?

Graves' disease

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?

Headache Impact Test

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

Hyoid bone

When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?

Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid

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

In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?

Mandible

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?

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 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

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?

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?

Notify the healthcare provider immediately.

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?

Previous injuries to the head and neck

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?

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?

Sternocleidomastoid

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

Tension

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?

This could be a sign of cancer

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of

a metastasis

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?

acromegaly

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

acromegaly.

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

approach the client posteriorly.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first

ask the client if touching the head is permissible.

As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition?

malignancy

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an

parotid gland enlargement.

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

swallow a small sip of water.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension

What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.)

1. The sternomastoid 2. The mandible 3. The midline of the neck

Which of the following clients is most likely to be diagnosed with migraine headaches?

A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room

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.

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 performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document this as an expected assessment finding

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

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

During the physical examination of a 65-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

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

The underlying bones

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.

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?

cerebrovascular accident

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?

goiter

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?

hyperthyroidism

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?

migraine

A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders?

tic douloureux

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia.

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a

tumor-related headache.

A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)

1. Use rails on stairs 2. Remove extension cords from high traffic areas 3. Avoid the use of throw rugs

A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply.

1. lethargy 2. constipation 3. cool skin 4. lower systolic blood pressure