Chapter 15 PrepU

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 client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

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

The nurse is palpating a client's cervical vertebrae. Which vertebra can be easily palpated when the neck is flexed and should help the nurse locate the other vertebrae?

C7

What is the most common type of hyperthyroidism?

Graves' disease

A nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?

Meningitis

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

Open the mouth

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

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 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 female client visits the clinic and tells the nurse that she frequently experiences 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

migraine headache.

The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?

red cheeks

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?

relieving factors

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

An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?

Cushing's syndrome

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

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 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

An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding?

Nodes are delimited on palpation

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?

Parkinson's disease

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

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

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 nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment?

characteristic symptoms

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

The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment

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 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

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.

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is

health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss.

What does the nurse assess the face for? (Select all that apply.)

Asymmetry Edema Involuntary movements

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply.

Alcohol abuse Recreational drug use Smokeless tobacco use Multiple sex partners

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

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

Nasolabial folds

A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?

Perform a focused assessment

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.

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 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 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.

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.