HA PREP U Head and Neck Chp. 14

Where is the temporal artery palpated?

Above the cheek bone near the scalp line Explanation: The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 209. (less)

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

Bell's palsy Correct Explanation: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pains that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporomandibular joint syndrome causes pain or crepitation with jaw movement. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 217. (less)

Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with patients who have paraplegia. These patients have been paralyzed by drunk drivers. How would the nurses who care for these patients best use the time spent with these teenagers?

Educating them about not drinking and driving Correct Explanation: Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these patients would not spend time with the teenagers teaching them how to turn the patients, fulfilling court requirements, or keeping the shelves restocked. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 216. (less)

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

False Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 214. (less)

What is the most common type of hyperthyroidism?

Graves' disease Correct Explanation: Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 220. (less)

The nurse is assessing the face of a client with a history of Parkinson's disease. Which of the following would the nurse most likely assess?

Masklike expression Correct Explanation: A client with Parkinson's disease exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.

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 Correct Explanation: Meningeal inflammation is a likely cause of this condition which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light and not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 213. (less)

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause Correct Explanation: All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 216. (less)

An 84-year-old woman is admitted to the hospital after a fall during which she hit her head. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The patient reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this patient?

Neck pain related to possible neck injury Correct Explanation: Diagnosis of a cervical spine injury is challenging and, in many cases, goes undiagnosed, especially in those lacking adequate health insurance. Patients at risk include those following a fall or collision and those with osteoporosis, advanced arthritis, cancer, or degenerative bone disease. The scenario does not indicate that the patient is on bed rest or that the patient has a limited range of motion. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 213. (less)

A clinic patient 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 Explanation: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Options A, C, and D are not correct. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 214. (less)

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 Correct Explanation: Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 215. (less)

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 Explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 209. (less)

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 Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 221. (less)

A 64-year-old patient is admitted to the hospital with severe diarrhea. When assessing the patient, 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 Correct Explanation: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigra). The scenario does not describe a patient with myxedema, scleroderma, or Bell's palsy.

The nurse is discharging a 26-year-old man who received 18 staples for a head laceration he got while mountain biking. What can the nurse focus on while doing discharge teaching?

Encourage the use of safety equipment Explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 215. (less)

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?

Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 221. (less)

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 Correct Explanation: This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 214. (less)

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 Explanation: Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 214. (less)

The nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient for

hyperthyroidism Correct Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 213. (less)

During the physical examination of the head and neck, the nurse palpates a lymph node after ensuring that it can move in which directions? (Select all that apply.)

• Up and down • Side to side Correct Explanation: A band of muscle or an artery can be accidentally mistaken as being a lymph node. If the mass can be moved up and down and side to side, it is a lymph node. Neither a muscle nor an artery can be moved up and down or side to side. The lymph node must move more than to the left or to the right. The lymph node is not immobile. Reference: Weber, J., & Kelley, J. H. (2010). Health Assessment in Nursing, 4th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 14: Head and Neck, p. 221. (less)