Assessing Head and Neck w/ PrepU
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 perspire less than others?" "Do you use more blankets that others at home? "Do you dress more warmly than other people? "Do you perspire more than others? "Have you lost weight?"
"Do you perspire less than others?" "Do you use more blankets that others at home? "Do you dress more warmly than other people? Because the client complains of feeling cold, the nurse should focus additional questions to assess for hypothyroidism.
Which of the following clients is most likely to be diagnosed with migraine headaches?
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
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 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.
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?
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.
A 66-year-old woman has come to the clinic with complaints of increasing fatigue over the last several months. She claims to frequently feel lethargic and listless and states that, "I can never seem to get warm, no matter what the thermostat is set at." How should the nurse proceed with assessment?
Assess the woman for hypothyroidism.
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
Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?
Educating them about not drinking and driving
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching?
Encourage the use of safety equipment
What is the most common type of hyperthyroidism?
Graves disease
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?
Health Seeking Behaviors The client has expressed the desire to seek assistance for her health issues even though she cannot afford a regular health care provider.
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 nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?
Meningitis
A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?
Notify the healthcare provider immediately. Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care.
Where are the superficial cervical lymph nodes located?
Superficial cervical lymph nodes are located superficial to the sternomastoid.
where are the preauricular nodes located?
The preauricular lymph nodes are located in front of the ear
Where are the tonsillar lymph nodes located?
The tonsillar lymph nodes are located near the mandible.
Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?
There is an infection in the area that these nodes drain. Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain.
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 nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter?
bruit If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis.
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
While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?
impending stroke A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms.
The nurse should ask about or assess which associated factors when a patient complains of cluster headaches? Select all that apply. rhinorrhea ptosis miosis lacrimation
rhinorrhea ptosis miosis lacrimation
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to?
swallow a small sip of water.
A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?
tension headache
What is the largest endocrine gland in the body?
thyroid gland
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
During the physical examination of a 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?
Atelectasis Atelectasis can cause the trachea to be pushed to one side from its midline position.
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. After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains
What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) Male gender Tobacco use Age older than 50 years Coffee drinker female gender
Male gender Tobacco use Age older than 50 years
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?
Parkinson's disease
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 Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain.
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved?
Sternocleidomastoid
While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for
acromegaly
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
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 patient 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.
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply. mediastinal mass atelectasis pneumothorax goiter preauricular node swelling
mediastinal mass atelectasis pneumothorax goiter
A 38-year-old accountant comes to the clinic for evaluation of a headache. The throbbing sensation is located in the right temporal region, and is an 8 on a pain scale of 1 to 10. It started a few hours ago, and she has noted nausea with sensitivity to light; she has had headaches like this in the past, usually less than one per week, but not as severe. She does not know of any inciting factors. There has been no change in the frequency of her headaches. She usually takes an over-the-counter analgesic, which results in resolution of the headache. Based on this description, what is the most likely diagnosis of the type of headache?
migraine This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.
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
