Health Assessment PrepU Chp. 12
What is the most common type of hyperthyroidism? a. Graves' disease b. Thyroid cancer c. Cushing's syndrome d. Moon face
a 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.
Which vessel is the nurse assessing if the major artery of the neck is being examined? a. Carotid b. Radial c. Temporal d. Jugular
a The common carotid artery exits the aorta and extends upward in the neck to branch into the internal and external carotid arteries. It is the major artery carrying blood to the brain. The internal jugular veins are located in the neck. The temporal artery is located between the top of the ear and the eye. The radial artery is located at the wrist.
A female client describes headache symptoms that seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurse's suspicion? a. "Does the headache tend to occur when you are stressed?" b. "Does the headache occur in conjunction with tightening of neck muscles?" c. "Does the headache tend to occur after a cold or sinusitis?" d. "Does the headache occur regularly with your menstrual cycle?"
d Eighteen percent of women have migraine headaches provoked by hormone fluctuations. None of the other types of headache have an onset associated with the menstrual cycle. Sinus headaches tend to occur following a cold or sinusitis. Tension headaches tend to occur with stress or anxiety and are associated with tightening of facial and neck muscles.
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. Cranial damage c. Bacterial thyroiditis d. Muscle tension
a Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client? a. Trigeminal neuralgia b. Tension headache c. Cluster headache d. Migraine headache
a Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.
Which of the following would the nurse document as an abnormal finding with lymph node assessment? a. Mobile b. Diameter: 0.75 cm c. Tender d. Discrete
c A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.
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. Wear nonslip shoes in the house. b. Use of guns should be supervised by an adult c. Always use seat belts. d. Avoid risky activities such as snowboarding
c The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations.
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? a. Trigeminal neuralgia b. Parkinson's disease c. Migraine headache d. Meningeal inflammation
d 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, 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.
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? a. C1 b. C5 c. C3 d. C7
d The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.
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? a. benign tumor b. thyroid cyst c. Hashimoto thyroiditis d. hyperthyroidism
d The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.
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. 4 b. 1 c. 3 d. 2
d The thyroid gland consists of two lateral lobes connected by an isthmus. Approximately one-third of the population has a third lobe that extends upward from the isthmus or from one of the two lobes.
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 medication for the rest of my life. b. I will take my thyroid hormone replacement medication once every week. c. I will complete the entire course of thyroid hormone replacement over six weeks. d. I must keep my follow up appointments to receive my thyroid hormone injections.
a After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.
A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache? a. Cluster b. Stress c. Tension d. Migraine
a Cluster headaches occur more often in young males, have a sudden onset and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening, localized to one eye with radiation into the facial and temporal areas. The person may report tearing of the eye, or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
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? a. Ask permission before palpating the head and neck b. Palpate the client's feet before palpating the head c. Have a nurse who is the same sex as the client perform the examination d. Avoid asking the client to remove her clothes for the examination
a Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.
The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? a. On each side between the top of the ear and the eye b. Inferior to the lower jaw beneath the client's tongue c. On each side of the client's face, anterior and inferior to the ears d. Bilaterally, parallel to and anterior to the sternomastoid muscle
a The temporal artery is located between the top of the ear and the eye. The submandibular glands are located inferior to the mandible, underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The internal jugular and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscle.
A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines? a. "When you consume alcohol, do you get a headache?" b. "Do you have any visual changes before the headache?" c. "Do they occur after you have been tense or anxious?" d. "Do you have any eye symptoms, such as tearing?"
b A typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes. <wbr />Asking about being tense or anxious would be appropriate to assess for a tension headache. Asking about alcohol or tearing would be appropriate for a cluster headache.
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? a. Difficulty with swallowing b. Previous injuries to the head and neck c. Changes in sleeping habits d. Stiffness in the right shoulder
b 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.
A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this? a. Tonsillar b. Posterior cervical c. Submandibular d. Occipital
b The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? a. At the angle of the mandible b. In the midline, a few centimeters behind the tip of the mandible c. Superficial to the sternomastoid d. In front of the ear
b The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.
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? a. Recreational drug use b. Smokeless tobacco use c. Multiple sex partners d. Alcohol abuse
b Tobacco use increases the risk of head and neck cancer. The nurse would need to perform a thorough head and neck examination. Alcohol abuse, recreational drug use, or multiple sex partners are not risk factors associated with head and neck cancer.
A young adult client has 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. Headache b. Shortness of breath c. Range of motion of the neck d. Range of motion of the arms and shoulders
c Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? a. Noted anatomists b. Their anatomical positions c. The underlying bones d. The underlying vascular network
c Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? a. C5 b. T2 c. C7 d. C3
c The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.
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? a. Myxedema b. Cushing's syndrome c. Parkinson's disease d. Nephrotic syndrome
c This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely.
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? a. Percussion b. Palpation c. Inspection d. Auscultation
d A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in clients with hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, or percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first? a. Thyroid gland b. Lymph nodes c. Mental status d. Hearing acuity
d A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.
