Nurs 204 - Chapter 15: Head and Neck

A nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements? a. Alcohol use is linked to head and neck cancers b. Asbestosis is linked to head and neck cancers c. most head and neck cancers are linked to smoking

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

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

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

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

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. C7 b. C5 c. C3 d. C4

a. C7

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? a. cervical fracture b. meningitis

meningitis

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? a. internal jugular veins b. external jugular veins c. Temporal arteries d. carotid arteries

Carotid arteries

A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action? a. Review the client's history for recent closed head injury. b. Suggest referral to orthopedic spine specialist. c. teach the patient to use neck exercises

Suggest referral to orthopedic spine specialist.

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 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? a. Assess the woman for parotid gland enlargement b. assess the woman for hypothyroidism c. assess the woman for hyperthyroidism d. assess the woman for Cushing's syndrome

b. Assess the woman for hypothyroidism.

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? a. Request a stat computed tomography scan to rule out a stroke. b. Request a neurology consult to determine the cause of facial muscle weakness. c. Discharge the patient because they have no other symptoms d. alert the rapid response team

b. Request a neurology consult to determine the cause of facial muscle weakness.

A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? a. pain without new symptomology b. stiff neck

b. stiff neck

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? a. Sinus b. Cluster c. Migraine d. Analgesic-rebound

c. migraine

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. palpate the carotid arteries simultaneously b. palpate the temporal arteries c. request an order for biopsy d. Notify the healthcare provider immediately.

d. Notify the healthcare provider immediately.

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? a. metastatic disease b. chronic infection c. Cushing's disease d. acute infection

d. acute infection

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 with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? a. consult the health care team about surgery b. assess the client regarding characteristics of the pain c. educate the patient on how to lessen the pain d. administer pain medication

b. Assess the client regarding characteristics of the pain.

A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? a. trapezius b. Sternocleidomastoid c. Masseter d. temporalis

b. Sternocleidomastoid

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. adults should supervise the use of guns b. always use seat belts c. wear nonslip shoes in the house d. avoid risky activities such as snowboarding

b. always use seat belts