Prep U:15-6

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During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.)

"Do you dress more warmly than other people? "Do you use more blankets that others at home? "Do you perspire less than others?"

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that 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?

Cluster

A client presents at the emergency room reporting "the worst headache I have ever had." What are the critical initial nursing interventions for this client? (Select all that apply.)

Conducting a focused history interview Physical examination for neurologic changes

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply.

Consists of two lateral lobes Produces hormones that increase the metabolic rate of most body cells Largest endocrine gland in the body Covered mostly by the sternomastoid muscles

The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?

Decreased serum calcium level on review of labwork.

Primary headaches are more worrisome than secondary headaches

False

What is the most common type of hyperthyroidism?

Graves disease

When assessing the head and neck, the nurse should realize that variations in skull or neck shape or size relate most to what?

Height and weight

The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply).

How recently have you consumed alcohol? When did you first notice the lump? Has the lump changed?

What structure is found midline in the tracheal area just beneath the mandible?

Hyoid bone

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 nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?

On the medial border of the mandible

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?

Range of motion of the neck

Nursing students are learning about assessment of the head and neck. What cultural considerations would the students learn to assess in relation to this area? (Select all that apply.)

Shape of the nose Shape of the eyes Shape of the lips

What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.)

The mandible The midline of the neck The sternomastoid

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage?

The notch on its superior edge

What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.)

Tobacco use Male gender Age older than 50 years

A family member of a client recovering from a traumatic brain injury asks the nurse what safeguards can be put in place at home to prevent future head injuries. What should the nurse instruct this family member? (Select all that apply.)

Use rails on stairs Remove extension cords from high traffic areas Avoid the use of throw rugs.

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.

When the nurse is preparing to assess the thyroid gland of a client with suspected hypothyroidism, why is it important to bring a cup of water to the physical examination?

to observe the movement of the thyroid gland


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