(PrepU) Chapter 15: Assessing Head and Neck

Where is the temporal artery palpated?

Above the cheek bone near the scalp line The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?

Consistency, delineation, mobility, tenderness Parameters of lymph node assessment include size, shape, delineation, mobility, consistency, and tenderness.

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?

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

The nurse is caring for a client who comes to the clinic reporting a lump by her ear. What are the symptoms of a cancerous lymph node?

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 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.

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the United States from Cambodia. The nurse should first

ask the client if touching the head is permissible. 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.

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

tension headaches. Tension headaches are dull, tight, and diffuse.

The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?

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.

What is the most common type of hyperthyroidism?

Graves' disease 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.

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect?

Hypothyroidism Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

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 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.

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?

Acute infection The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease.

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?

C7 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.

An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment?

Cardiovascular Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.

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 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.

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.

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 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 client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?

hypothyroidism Manifestations of hypothyroidism include an edematous face, hands, and legs. Manifestations of scleroderma include a hardening face with thinning facial skin. Manifestations of hyperthyroidism include warm, smooth, moist skin and exophthalmos. Manifestations of Cushing's syndrome include a moon-shaped face with reddened cheeks and increased facial hair.

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

Administer migraine medication A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests migraine; whereas a constant, unremitting, general headache that is described as a feeling of a tight band around the head and lasts for days, weeks, or even months is usually characteristic of a tension headache treated with over the counter or prescribed pain medication. Secondary headaches with varying symptoms such as a tight stiff neck and body aches are associated with underlying pathology such as a common cold or meningitis, often diagnosed by spinal tap.

When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?

The underlying bones Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.

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?

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.