prep u#12: head & neck (lymph nodes)

Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?

A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism.

Where is the temporal artery palpated?

Above the cheek bone near the scalp line

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

A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?

Fatigue, cold intolerance, and constipation. hypothyroidism

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.

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

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

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

RC: Cushing's syndrome

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

cup of water *to help swallow for examination

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

dehydration

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?

hearing acuity

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

nodularity fibrotic changes with aging

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

open the mouth easy access to the joint

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

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

sit in an upright position

symptoms in thyroid crisis

tachypnea nausea anxiety

Which of the following would the nurse document as an abnormal finding with lymph node assessment?

tender is an abnormal finding suggesting acute infection

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?

cancer (larger than 1 cm)

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?

fixed to underlying tissue

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify?

hyoid bone cricoid cartilage

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 typical migraine headache has prodromal symptoms that may include visual disturbances, vertigo, tinnitus, and/or numbness or tingling of the fingers and toes.