Bates -- Chapter 10

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?

"Loss of sensation in the toes is an age-related change."

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?

2

A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?

A sound of turbulent blood flow in the thyroid

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

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

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 pathophysiological cause for this finding is related to what disease process?

Atelectasis

A client admitted to the hospital for a gastrointestinal bleed is now experiencing right-sided facial weakness. The nurse assesses the client and determines no other neurological deficits exist. The nurse determines the client is most likely exhibiting signs of which of the following disorders?

Bell palsy

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

When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?

Cup of water

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?

Decreased strength of temporal artery pulsations

The nurse detects enlarged, tender, preauricular nodes in a client. Which of the following would the nurse need to examine for possible infection?

Eyes

After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?

Female gender

What is the most common type of hyperthyroidism?

Graves' disease

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

During your physical examination of the client 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

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

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

Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?

Modes of transportation are the leading cause

Which of the following would the nurse consider to be an urgent situation?

New onset chest pain

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

On each side between the top of the ear and the eye

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 nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?

Referral for further assessment of thyroid function

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

The nurse is assessing a client's thyroid by having the client swallow a small sip of water. What will the nurse document as an expected finding?

The thyroid cartilage and cricoid cartilage move upward symmetrically.

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.

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?

acromegaly

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

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?

cerebrovascular accident

A nurse is providing care to an 86-year-old client. The nurse identifies which of the following finding(s) as a normal age-related head and neck change? Select all that apply.

decreased range of motion of the neck cervical curvature of the spine decreased temporal pulse

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

migraine headache

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