The Point Assessing Head and Neck

A nurse palpates an enlarged, hard, and nontender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more date about this finding? a. Abdomen and thoracic area for changes associated with malignancy b. Upper extremities for changes in sensation, movement, and range of motion. c. Head and neck area for signs of infection or inflammation d. Spinal cord area for signs of degeneration and decreased mobility

a. Abdomen and thoracic area for changes associated with malignancy Rationale: The supraclavicular lymph nodes are located by hooking the fingers over the clavicles and feeling deeply between the clavicles and the sternomastoid muscles. Normally, these lymph nodes should not be palpable. An enlarged, hard, nontender left-sided supraclavicular node may be an indication of malignancy of the abdomen or thorax. Enlarged, hard, and nontender supraclavicular nodes would not affect sensation, movement, or range of motion. Infection or inflammation in the head and neck region most often enlarges the nodes closet to the site affected, such as preauricular or postauricular with ear infections. Degeneration within the spinal cord does not affect lymph nodes.

During the physical examination of the client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process? a. Atelectasis b. Endocarditis c. Tuberculosis d. Bronchitis

a. Atelectasis Rationale: Atelectasis can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membranes of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.

A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a. Auscultate with the bell over the lateral lobes b. Immediately notify the HCP c. Document the findings in the nurse notes d. Ask the client about past history of hypothyroidism

a. Auscultate with the bell over the lateral lobes Rationale: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced bc of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the HCP notified once assessment is complete to obtain further orders.

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? a. Auscultation b. Inspection c. Percussion d. Palpation

a. Auscultation Rationale: A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in clients with hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, or percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.

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. a. Produces hormones that increase the metabolic rate of most body cells b. Largest endocrine gland in the body c. Consists of two lateral lobes d. Covered mostly by the sternomastoid muscles e. Located anterior and inferior to the ears and behind the mandible f. Produces saliva

a. Largest endocrine b. Produces hormones c. Consists of two d. Covered mostly Rationale: The thyroid gland is the largest endocrine gland in the body. It produces thyroid hormones that increase the metabloic rate of most body cells. The thyroid gland consists of two lateral loies that curve posteriorly on both sides of the trachea and esophagus and are mostly covered by the sternomastoid muscles. The parotid glands, not the thyroid, are located on each side of the face, anterior and inferior to the ears and behind the mandible. The submandibular glands, not the thyroid, produce saliva.

A nurse need to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this? a. On the medial border of the mandible b. At the angle of the mandible on the anterior edge of the sternomastoid muscle c. A few centimeters behind the tip of the mandible d. At the posterior base of the skull bone

a. On the medial border of the mandible Rationale: The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few centimeters behind the tip of the mandible.

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

a. Previous injuries to the head and neck Rationale: Previous head or neck injuries may cause limitations in movements 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.

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. Acute infection c. Chronic infection d. Cushing's disease

b. Acute infection Rationale: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender are 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 nodes findings may vary in Cushing's disease.

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 bc of final exam and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache? a. Tension b. Cluster c. Migraine d. Stress

b. Cluster Rationale: Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents? a. Most firearm incidents are accidental b. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens c. Falls occur more frequently in the younger population d. Females have twice the risk that males do

b. Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens. Rationale: Among kids and teens, concussions in sports and motor vehicle accidents account for the largest number of TBIs. It is not surprising that males are more likely to sustain a TBI than females due to more risk-taking behaviors and contact sports or hazardous occupations. Firearm incidents are not listed as a significant cause of TBIs. For older adults, falls, and maltreatment account for most TBIs.

A client presents to the health care clinic with reports of a 12-pound unintentional weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states that she does not have insurance and cannot afford to see a regular health care provider. What nursing diagnosis can the nurse confirm from this data? a. Ineffective Health Maintenance b. Health Seeking Behaviors c. Imbalanced Nutrition: Less Than Body Requirements d. Alteration in Fluid Balance

b. Health Seeking Behaviors Rationale: The client has expressed the desire to seek assistance for her health issues even though she cannot afford a regular health care provider. There is not data to support imbalanced Nutrition bc the client states she is hungry all the time. More data needs to be collected about how much the client is eating. Major defining characteristics for Ineffective Health Maintenance do not exist even though the client does not have insurance bc she is at the health care clinic. To confirm the diagnosis of Alteration in Fluid Balance, the nurse needs to perform further assessment.

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? a. Migraine headache b. Meningeal inflammation c. Parkinson's disease d. Trigeminal neuralgia

b. Meningeal inflammation Rationale: Meningeal inflammtion 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.

During the physical examination of a 60-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client? a. Notify the HCP for further diagnostic tests b. Recognize the weakened pulsation as an age-related change c. Assess the client for a decrease in level of consciousness d. Check blood pressure as it can be due to hypotension

b. Recognize the weakened pulsation as an age-related change. Rationale: The nurse should consider the weakened pulse as an age-related change. The temporal arteries may have weak pulsation due to a decrease in the strength of the pulse in old age. The nurse may check the BP, but it is not the most appropriate action. The nurse may inform the HCP, but the condition is not due to any underlying pathology. Decrease in the blood flow to the temporal artery will not affect the level of consciousness.

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? a. Trigeminal neuralgia b. Preauricular adenitis c. Bell's palsy d. Temporomandibular joint syndrome

c. Bell's palsy Rationale: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pain that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporrmandibular joint syndrome causes pain or crepitation with jaw movement.

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

c. Carotid artery Rationale: 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.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a. Soft in consistency b. Round and 8 mm in size c. Fixed to underlying tissue d. Mobile from side to side

c. Fixed to underlying tissue Rationale: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

A nurse needs to examine a client's thyroid as part of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam? a. Hyperextend the head to the side being examined b. Flex the head away from the side being examined c. Flex the head toward the side being examined d. Hyperextend the head, keeping midline alignment

c. Flex the head toward the side being examined Rationale: To correctly examine the thyroid, the nurse should stand behind the client and ask him to lower the chin and turn the head toward the side being examined. This action helps relax the client's neck muscles.

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. Temporalis b. Masseter c. Sternocleidomastoid d. Trapezius

c. Sternocleidomastoid Rationale: 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 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. C1 b. C3 c. C5 d. C7

d. C7 Rationale: 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.

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection? a. Neck tenderness b. Range of motion c. Thyroid size d. Head position

d. Head position Rationale: While collecting history, the nurse would be able to inspect the client to see in what position the head was being held. Range of motion would require the nurse to give the client commands and would be performed during the physical assessment. Neck tenderness and thyroid size would require the use

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? a. Tension headache b. Temporal arteritis c. Bell's palsy d. Migraine headache

d. Migraine headache Rationale: 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.

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment? a. Temporomandibular Joint b. Earlobe placement c. Preauricular nodes d. Nasolabial folds

d. Nasolabial folds Rationale: The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that cannot be inspected as they are very small. Earlobe placement is not an appropriate method to determine facial symmetry.

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? a. Preauricular nodes b. Temporomandibular joint c. Earlobes d. Nasolabial folds

d. Nasolabial folds Rationale: The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that are not inspected but palpated. Earlobes are not an appropriate feature to use to determine facial symmetry.

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? a. Sit upright b. Perform a chewing action c. Sit without moving d. Open the mouth

d. Open the mouth Rationale: While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate.

Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? a. Thyroid enlargement b. Bell's palsy c. Acute pharyngitis d. Parotid enlargement

d. Parotid enlargement Rationale: Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat, which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes.