Ch. 15 Head and Neck

During the health interview of the head and neck, the patient tells the nurse about having a lump in the neck. Which question would the nurse ask to assess manifestations associated with this lump?

"Do you have difficulty swallowing?

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 data about this finding?

Abdomen and thoracic area for changes associated with malignancy 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.

When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?

Attempting to roll the structure up and down and side to side

The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?

Decreased serum calcium level on review of labwork, Parathyroid glands produce calcitonin, which moves calcium into the bones; therefore decreasing the serum calcium levles

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?

Flex the head toward the side being examined Explanation: 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 to relax the client's neck muscles.

When assessing a patient with Graves disease, how would you expect the thyroid gland to be?

soft

A male college student presents to the student health clinic with reports of night-time headaches for the past two weeks. He denies nausea and photosensitivity but states he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?

Cluster

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 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 headache

A client presents at the emergency room reporting "the worst headache I have ever had." What are critical nursing behaviors for this client? (Select all that apply.)

• Physical examination for neurologic changes • Focused history

The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply.

• photophobia • throbbing • recurrent