PrepU (3-10)

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) C3 B) C5 C) C7 D) T2

C7

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes? -Increased size of a single thyroid nodule -Tenderness of lymph nodes on palpation -Decreased strength of temporal artery pulsations -A nonpalpable carotid pulse

Decreased strength of temporal artery pulsations The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age

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) Sternocleidomastoid b) Trapezius c) Temporalis d) Masseter

Sternocleidomastoid The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).

The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse? (Select All That Apply) Document findings Palpate for thyroid Ask about recent injuries Notify the health care provider

• Notify the health care provider Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.

A male client can neither turn his head against resistance nor shrug his shoulders. The nurse documents a deficit in the functioning of which cranial nerve?

Accessory (XI) The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) are involved with eye muscle movement. The hypoglossal (XII) is involved with tongue muscles.

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal? a) Brain tumor b) Paget disease c) Acromegaly d) Parkinson disease

Acromegaly The skull and facial bones are larger and thicker in acromegaly. Acorn-shaped enlarged skull bones are seen in Paget's disease. Brain tumor and Parkinson's disease would not change the shape, size, or configuration of the skull.

The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The patient was not wearing a helmet. When assessing the patient's head and neck, the nurse should prioritize the assessment for which of the following? Strain Cyanosis Pallor Bleeding

Bleeding Patients with acute head injuries and neurological changes must be quickly and accurately assessed by the health care team. Stabilization of the head and neck is essential to avoid further neurological injury. Any history of trauma to the head, neck, or both warrants a careful assessment of these structures for bleeding, swelling, loss of mobility, or pain.

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available? -Penlight -Cup of water -Centimeter-scale ruler -Tongue depressor

Cup of water When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. A cup of water would aid in swallowing

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? Cervical fracture Meningitis Migraine Measles

Meningitis Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

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) Changes in sleeping habits b) Difficulty with swallowing c) Stiffness in the right shoulder d) Previous injuries to the head and neck

Previous injuries to the head and neck 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. (less)

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle? A. Infraspinous B. Sternomastoid C. Trapezius D. Platysma

Sternomastoid The superficial cervical nodes are in the area superficial to the sternomastoid muscle, whereas the deep cervical chain is deeply within and around it. The supraclavicular nodes lie deeply between the clavicles and sternomastoid muscle.

Which of the following would the nurse document as an abnormal finding with lymph node assessment? a) Tender b) Diameter: 0.75 cm c) Mobile d) Discrete

Tender A lymph node that is tender is an abnormal finding suggesting acute infection. Size less than 1 cm, mobile, and discrete indicate normal findings.

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate? Cushing syndrome scleroderma Parkinson disease acromegaly

acromegaly Acromegaly is characterized by enlargement of the facial features (nose, ears) and the hands and feet. Parkinson disease is caused by decreased dopamine manifests with rigidity, bradykinesia, postural instability (slow, jerky movements), cogwheel gait, shuffling, and mask-like facies. Cushing syndrome may present with a moon-shaped face, reddened face, and increased facial hair. Scleroderma is an autoimmune disorder that can cause changes in the skin, blood vessels, muscles, and internal organs; skin may be tight and hard on the face and hands.

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? thyroid cyst Hashimoto thyroiditis hyperthyroidism benign tumor

hyperthyroidism 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? 1 2 3 4

2. 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.

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions? (Select All That Apply) Wear nonslip shoes in the house. Use of guns should be supervised by an adult. Avoid risky activities such as snowboarding. Always use seat belts.

Always use seat belts. 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 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 Have a nurse who is the same sex as the client perform the examination B Ask permission before palpating the head and neck C Palpate the client's feet before palpating the head D Avoid asking the client to remove her clothes for the examination

Ask permission before palpating the head and neck 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 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. External jugular vein b. Temporal artery c. Carotid artery d. Internal jugular vein

Carotid artery It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain. Compression of the internal or external jugular veins would not be as significant as compressing the carotid arteries as doing so would not reduce blood supply to the brain. The temporal artery, a major artery, is located between the eye and the top of the ear, and would not be affected by palpation of the neck.

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? Look for involvement of other regions of the body Look for a source such as infection in the area that it drains Assess for meningitis Assess for dietary changes

Look for a source such as infection in the area that it drains explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

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? -Myxedema -Parkinson's disease -Cushing's syndrome -Nephrotic syndrome

Parkinson's disease 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.

The nurse is caring for a patient who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node? a) The node is fixed and rubbery. b) The node matches the node on the opposite side of the body. c) The node is less than 1 cm in size and feels boggy. d) The node is soft and moves freely.

The node is fixed and rubbery. Lymph nodes larger than 1 cm, fixed, irregular, hard, or rubbery require emergency investigation. Such signs raise the possibility of cancer.

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? This could be a sign of an embolus This could be a sign of a parotid stone This could be a sign of cancer This could be a sign of pneumothorax

This could be a sign of cancer Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.

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? Migraine headache Cluster headache Trigeminal neuralgia Tension headache

Trigeminal neuralgia 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.

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information? A. onset B. location C. treatment D. relieving factors

relieving factors Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers.