Chapter 15 Head & Neck

Where is the temporal artery palpated? A. Above the cheek bone near the scalp line B. Just left of midline at the base of the neck 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

A. Above the cheek bone near the scalp line

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 seatbelts B. Wear nonslip shoes in the house C. Avoid risk activities such as snowboarding D. Use of guns should be supervised by an adult

A. Always use seat belts

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

A. Arthritic changes of the cervical spine

A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale of 1-10. This subjective data should be documented in which section of the assessment? A. Characteristic symptoms B. Associated manifestations C. Relieving factors D. Location

A. Characteristic symptoms

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. Fulfilling the court requirements C. Teaching them about how to turn these clients every 2 hrs D. Keeping the shelves restocked

A. Educating them about not drinking and driving

A female client visits the clinic and tells the nurse that she is frequently experiencing severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a A. Migraine headache B. Cluster headache C. Tension headache D. Tumor-related headache

A. Migraine headache

A nurse documents which of the following as a normal finding when examining the thyroid gland of an older adult client? A. Nodularity B. Tenderness C. Enlargement D. Bruits

A. Nodularity

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

A. Notify the health care provider immediately

A young adult client just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next? A. Range of motion of the neck B. Headache C. Shortness of breath D. Range of motion of the arms and shoulders

A. Range of motion of the neck

A 29yr old computer programmer comes to the offices 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? A. Tension B. Migraine C. Cluster D. Analgesic rebound

A. Tension

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

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

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? A. 1 B. 2 C. 3 D. 4

B. 2

The nurse is palpating a clients neck as a part of physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? A. Internal jugular vein B. Carotid artery C. External jugular vein D. Temporal artery

B. Carotid artery

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 that possible cause of these signs? A. Myxedema B. Cushing's disease C. Scleroderma D. Bell's palsy

B. Cushing's disease

A female client ask a nurse why is seems like her headaches are more severe and longer in duration that male friends who also have migraines. What is the best response by the nurse? A. There is no difference in how migraines affect males and females B. Hormones affect the severity of migraine headaches C. People experience different symptoms with migraines D. The severity of migraines is usually related to genetics

B. Hormones affect the severity of migraine headaches

A client presents to the emergency department with reports of neck pain and 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. Migraine headache B. Meningeal inflammation C. Trigeminal neuralgia D. Parkinson's disease

B. Meningeal inflammation

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. Administer acetaminophen for the pain B. Notify health care provider C. Continue to monitor the client D. Document findings

B. Notify the health care provider (may be a sign of meningeal inflammation)

A client complains of recurring headaches that are worse when first waking up in the morning and with coughing or sneezing. What would be the nurses most appropriate action? A. Ask the doctor for an order for an MRI B. Perform a focused assessment C. Prepare the client for a spinal tap D. Perform a generalized assessment

B. Perform a focused assessment

The nurse is preparing to assess the neck of an adult client. To inspect movement of the clients thyroid gland, the nurse should ask the client to A. Inhale deeply B. Swallow a small sip of water C. Cough deeply D. Flex the neck to each side

B. Swallow a small sip of water

Which risk factor for traumatic brain injuries (TBI) should a nurse include in a discussion about prevention of a group of adolescents? A. Females have twice the risk that males do B. Most firearms incidents are accidental C. Concussions in sports and motor vehicles accidents cause the largest number of TBLs in teens D. Falls occur more frequently in the younger population

C. Concussions in sports and motor vehicles accidents cause the largest number of TBLs in teens

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the findings. Which should the nurse attribute to age related physiological changes? A. Increased size of a single thyroid nodule B. A nonpalpalble carotid pulse C. Decreased strength of temporal artery pulsations D. Tenderness of lymph nodes on palpation

C. Decreased strength of temporal artery pulsations

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? A. I must take thyroid hormone replacement for the rest of my life B. I will complete the entire course of thyroid hormone replacement over six weeks C. I must keep my follow up appointments to receive my thyroid hormone injections D. I will take my thyroid hormone replacement medications once every week

C. I must keep my follow up appointments to receive my thyroid hormone injections

A nurse has completed an assessment of a client's lymph nodes which of the following data would the nurse document as an abnormal finding? A. Diameter: 0.75cm B. Mobile C. Tender D. Discrete

C. Tender

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

D. Acromegaly

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

D. Assess the client regarding characteristics of the pain

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. Bell palsy B. Temporal arteritis C. Trigeminal neuralgia D. Cerebrospinal accident

D. Cerebrovascular accident

A client presents at the clinic for a routine checkup. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73 degrees F. The nurse also notes that the client has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect? A. Effects of age related changes B. Brain tumor C. Hyperthyroidism D. Hypothyroidism

D. Hypothyroidism

You should begin the assessment of the patients head with which action? A. Palpating the patient's scalp B. Inspecting the patient's head size and shape C. Palpating the patient's lymph nodes D. Inspecting the patient's face

D. Inspecting the patients head size and shape

A 73 yr old women 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 condition. 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. Cushing's syndrome B. Nephrotic syndrome C. Myxedema D. Parkinson's disease

D. Parkinson's disease

Palpation of a 15 yr old boys submandibular lymph nodes reveals them to be enlarged and tender what is the nurses most reasonable interpretation of this assessment findings? A. The boy requires assessment of his thyroid gland B. There is an inflammatory response in the musculature of the boys neck 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

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 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible A. Cancerous lesions B. Arterial occlusion C. Inner ear disease D. Trigeminal neuralgia

D. Trigeminal neuralgia

Which assessment findings of the head should you associate with a cerebrovascular accident (CVA) (select all that apply) - erythema - drooping - A "mask-like" face - unilateral paralysis - facial weakness

Dropping, Unilateral paralysis, and facial weakness

Headaches cause significant pain and distress to patients, but they are not associated with disease or major health problems True/False

False

During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse should suspect which of the following? A. Trigeminal neuralgia B. Migraine headache C. Meningitis D. Temporomandibular joint dysfunction

Trigeminal neuralgia