CH15-PU
What structure is found midline in the tracheal area just beneath the mandible?
the hyoid bone
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
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
An 81-year-old client complains of neck pain and demonstrates decreased range of motion on examination. Which of the following causes should the nurse most suspect in this client?
Arthritis
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?
Asses the women 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
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism?
Auscultation
The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening?
Bruit
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 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?
Carotid artery
Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?
Concussions in sports and motor vehicle accidents cause the largest number of TBI's in teens
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics?
Consistency, delineation, mobility, tenderness
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII
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?
Grave's disease
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
The nurse does a health history. The patient states he has lost 30 pounds in the last couple months without really trying. The patient also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the patient fo
Hyperthyroidism
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing?
Hypothyroidism
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. The nurse also notes that the patient has gained 10 pounds since her last visit 9 months ago. What might the nurse suspect?
Hypothyroidism
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 sideline, a few centimeters behind the tip of the mandible
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
The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?
Lymph node
What activity is known to aggravate a tension headache?
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 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 instruction to the client will help facilitate examination of the temporomandibular joint by the nurse
Open the mouth
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action?
Perform a focused assessment
The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to
Sit in an upright position
The nurse is assessing an elderly woman who reports lethargy and weakness. During the examination, the nurse notices that the client's face is drooping slightly on the right side. Why does this finding require emergency intervention?
The client could be experiencing a stroke
The nurse is caring for a patient 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
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
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
Primary headaches are more worrisome than secondary headaches. (t/f)
f
A normal assessment of the neck would include palpation of the thyroid isthmus. Where would the nurse find the isthmus? Just above the thyroid cartilage Between the thyroid and the cricoid cartilages Just below the cricoid cartilage In front of the sternocleidomastoid muscle SUBMIT ANSWER
just below the cricoid cartilage
A client visits the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 °C (100 °F). The nurse suspects the client is experiencing symptoms of
migraine headache
While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?
Bell's Palsy
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
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
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 performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse? a) Document findings b) Palpate for thyroid c) Notify the health care provider d) Ask about recent injuries
Notify the health care provider Explanation: Tracheal deviation is an emergency and the health care provider should be notified immediately. The client should be provided nursing care and further head and neck assessment along documentation can occur once emergency has subsided.
Where should a nurse place the hands to palpate the submandibular lymph nodes?
On the medial border 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?
Previous injuries to the head and neck
The nurse is presenting an educational event for a local civic group about the risk factors for neck cancer. What would the nurse list? (Select all that apply.) A) Female gender B) Male gender C) Age older than 40 years D) Tobacco use E) Age older than 50 years
b,d,e
When conducting a generalized assessment of a new client, for what would the nurse inspect the neck?
limitations in movement
An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headaches that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a a) tumor-related headache. b) tension headache. c) migraine headache. d) cluster headache.
tumor-related headache. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
A nurse is caring for an adult client who has just undergone surgery to remove a thyroid tumor. The nurse is assessing for symptoms of hyperthyroidism. What are some of the symptoms of hypermetabolism? Select all that apply.
-Tachycardia -Diarrhea -Anxiety
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 or A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A
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
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
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
An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of?
Cushing's Syndrome
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph? The drainage pattern can help the nurse understand why the disease is spreading. Nurses need to follow lymph patterns to track the course of a disease. The drainage pattern may help pinpoint a fluid or electrolyte imbalance. Enlargement of a node may be a sign of pathology that is distant from that node.
Enlargement of a node may be a sign of pathology that is distant from that node.
A client's lab results reveal thyroid stimulating hormone level of 7.0 mU/L; Free T4 0.5 ng/dl; Total T3 60 ng/dl; and Total T4 3mdmg/dl. Based on these lab results what symptoms should the nurse expect the client to reveal?
Fatigue, cold intolerance, and constipation.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? a) Mobile from side to side b) Soft in consistency c) Round and 8 mm in size d) Fixed to underlying tissue
Fixed to underlying tissue Explanation: 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.
When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head? a) Facial skin colorWhat structure is found midline in the tracheal area just beneath the mandible? b) Sclera color c) Nasal mucosa color d) Hair color
Hair color Explanation: When describing a client's head, the nurse should include 2 categories of findings, the client's hair color and the presence or absence of abnormalities of the skull. Sclera color is included in documentation of the eyes. Nasal mucosa color is included in documentation regarding the nose. Facial skin color is best included when documenting data regarding the skin
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
A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is
Health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss.
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? a) Hyperthyroidism b) Brain tumor c) Diabetes d) Impending stroke
Impending stroke Explanation: 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. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter, bruit, and sudden weight loss, but not with any of the symptoms listed.
In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction?
Mandible
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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?
Meningeal Inflammation
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. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth
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
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?
Recognize the weakened pulsation as an age-related change
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?
Red cheeks
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
Reduction of the blood supply to the brain
A client complains of pain, numbness, and tingling in the upper extremities for several weeks before coming to the clinic for evaluation. What is the nurse's best action?
Suggest a referral to orthopedic spine specialist
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 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
While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible
Trigeminal neuralgia
During the physical examination of a client, a nurse detects a thick and tender temporal artery. Which additional assessment should the nurse perform to rule out the possibility of temporal arteritis?
Vision Acuity
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.) a) "Do you dress more warmly than other people? b) "Do you perspire less than others?" c) "Do you perspire more than others?" d) "Have you lost weight recently?" e) "Do you use more blankets that others at home?
a,b,e
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
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
A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In which part of the subjective section of the physical examination should the nurse document this information?
relieving factors
Where is the temporal artery palpated?
Above the cheek bone near the scalp line
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
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
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
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 client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? a) I will complete the entire course of thyroid hormone replacement over six weeks. b) I must keep my follow up appointments to receive my thyroid hormone injections. c) I will take my thyroid hormone replacement medication once every week. d) I must take thyroid hormone replacement medication for the rest of my life.
I must take thyroid hormone replacement medication for the rest of my life. Explanation: 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.
An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?
Impaired comfort related to possible neck injury
A client is being assessed for a headache. Symptoms include throbbing and severe pain lasting for the last 8 hours. The client also has a history of vomiting with the headache. What type of headache could these findings indicate?
Migraine
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? a) Shortness of breath b) Headache c) Range of motion of the arms and shoulders d) Range of motion of the neck
Range of motion of the neck Explanation: 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. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next. (less)
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 toughing the head is permissible
Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?
Lymphatic
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? a) Cluster b) Tension c) Migraine d) Analgesic rebound
b
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 palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a) Ask the client about past history of hypothyroidism b) Document the findings in the nurse notes c) Immediately notify the health care provider d) Auscultate with the bell over the lateral lobes
Auscultate with the bell over the lateral lobes Explanation: 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 because 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 health care provider notified once assessment is complete to obtain further orders.
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
What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.)
• The sternomastoid • The mandible • The midline of the neck Explanation: The anterior triangle is bordered by the mandible above, the sternomastoid laterally, and the midline of the neck medially.
