Chap 12 PrepU
Tension Explanation: This is a description of a typical tension headache.
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 Migraine Cluster Analgesic rebound
Arthritic changes of the cervical spine Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles
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 Bacterial thyroiditis Cranial damage Muscle tension
Ask permission before palpating the head and neck Explanation: 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. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.
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? Avoid asking the client to remove her clothes for the examination Have a nurse who is the same sex as the client perform the examination Ask permission before palpating the head and neck Palpate the client's feet before palpating the head
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.
A nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique? Inspection Auscultation Palpation Percussion
Female gender Explanation: Risk factors for traumatic brain injury include transportation accidents, violence (often firearms related), falls, male gender, failure to use protective equipment, and participation in contact sports.
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? Firearm violence Female gender Contact sports Transportation accidents
Arthritis Explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
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? Meningeal inflammation Stress Injury to the sternomastoid Arthritis
cluster headaches. Explanation: Other vascular headaches may be caused by fever or high blood pressure ("cluster headaches").
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of cluster headaches. migraine headaches. tension headaches. tumor-related headaches.
Look for a source such as infection in the area that it drains Explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? Assess for meningitis Look for involvement of other regions of the body Look for a source such as infection in the area that it drains Assess for dietary changes
Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding? A tumor Hypothyroidism Graves' disease Nephrotic syndrome
Acute infection Explanation: The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and 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 node findings may vary in Cushing's disease.
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? Metastatic disease Chronic infection Acute infection Cushing's disease
Graves' disease Explanation: Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.
What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer
The underlying bones Explanation: Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? Noted anatomists The underlying bones Their anatomical positions The underlying vascular network
Attempting to roll the structure up and down and side to side Explanation: While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance
Assess the client's blood pressure. Explanation: Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? Assess the client's blood pressure. Provide medication for pain relief. Inquire about family history of headaches. Review the client's medical record.
Assess the woman for hypothyroidism. Explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.
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? Order tests to rule out an overactive thyroid gland. Assess for other signs and symptoms of Cushing's syndrome. Palpate the woman's parotid gland for enlargement. Assess the woman for hypothyroidism.
Notify the healthcare provider immediately. Explanation: 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.
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. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.
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.
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. I will complete the entire course of thyroid hormone replacement over six weeks. I must keep my follow up appointments to receive my thyroid hormone injections. I will take my thyroid hormone replacement medication once every week.
Hypothyroidism Explanation: 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.
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? Effects of age-related changes Brain tumor Hyperthyroidism Hypothyroidism
Meningeal inflammation Explanation: Meningeal inflammation 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 and 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.
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? Migraine headache Meningeal inflammation Trigeminal neuralgia Parkinson's disease
Previous injuries to the head and neck Explanation: Previous head or neck injuries may cause limitations in movement 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.
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 Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client? Cluster headache Tension headache Migraine headache Trigeminal neuralgia
Administer migraine medication Explanation: A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests migraine; whereas a constant, unremitting, general headache that is described as a feeling of a tight band around the head and lasts for days, weeks, or even months is usually characteristic of a tension headache treated with over the counter or prescribed pain medication. Secondary headaches with varying symptoms such as a tight stiff neck and body aches are associated with underlying pathology such as a common cold or meningitis, often diagnosed by spinal tap.
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 narcotic pain medication Administer migraine medication Administer medication for common cold Prepare the client for a spinal tap
A sound of turbulent blood flow in the thyroid Explanation: A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical.
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? Audible referred breath sounds at the site of the thyroid An audible S3 sound at the site of the thyroid A sound of turbulent blood flow in the thyroid Irregular S1 and S2 rhythms in the thyroid
Decreased strength of temporal artery pulsations Explanation: The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age.
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? Increased size of a single thyroid nodule A nonpalpable carotid pulse Decreased strength of temporal artery pulsations Tenderness of lymph nodes on palpation
Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? Document this as an expected assessment finding Refer the client to the primary care provider promptly Perform a focused endocrine assessment Position the client supine and reattempt palpation
Auscultation Explanation: 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 assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? Inspection Palpation Auscultation Percussion
C7 Explanation: The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae? C3 C5 C7 T2
2 Explanation: The thyroid gland consists of two lateral lobes connected by an isthmus. Approximately one-third of the population has a third lobe that extends upward from the isthmus or from one of the two lobes.
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? 1 2 3 4
Compressing the arteries bilaterally Explanation: The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.
A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated? Asking the client to flex his or her neck Compressing the arteries bilaterally Performing the examination while the client is seated Asking the client to swallow water
Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.
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 Referral for assessment of cranial nerve function Referral for assessment of lymphatic system function Referral for further assessment of swallowing ability
Headache Impact Test Explanation: The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.
A nurse needs to assess a client who is experiencing chronic headache to determine how it is affecting her activities of daily living. Which of the following interventions should the nurse implement? A mnemonic assessment tool Headache Impact Test Auscultation Family health history questionnaire
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 nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Immediately notify the health care provider Document the findings in the nurse notes Auscultate with the bell over the lateral lobes Ask the client about past history of hypothyroidism
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry, auscultates for bruits, and palpates for tumors, masses, size, and tenderness. Percussion is not necessary.
A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique? Inspection Auscultation Palpation Percussion
This could be a sign of dehydration Explanation: A depressed fontanel may indicate dehydration. This is not a normal finding and does need further assessment. A depressed fontanel does not indicate increased intracranial pressure, possible neurological disorder, or a sign of physical abuse.
A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment? This could be a sign of dehydration This is a sign of a possible neurological disorder This could be a sign of increased intracranial pressure This could be a sign of physical abuse
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.
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 Headache Shortness of breath Range of motion of the arms and shoulders
"Do you dress more warmly than other people? "Do you use more blankets than others at home? "Do you perspire less than others?" Explanation: Because the client complains of feeling cold, the nurse should focus additional questions to assess for hypothyroidism. These questions would include "Do you dress more warmly than other people?", "Do you use more blankets than others at home?", and "Do you perspire less than other?" The questions "Do you perspire more than others?" and "Have you lost weight recently?" would be appropriate to assess for hyperthyroidism.
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 dress more warmly than other people? "Do you use more blankets than others at home? "Do you perspire more than others?" "Do you perspire less than others?" "Have you lost weight recently?"
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. Migraine headache is characterized by pain around the eyes, temples, cheeks, or forehead. Meningitis would be manifested by sudden head and neck pain, with fever and neck stiffness. Temporomandibular joint dysfunction is manifested by limited range of motion, swelling, tenderness, or crepitation in the jaw area.
During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem? Trigeminal neuralgia Migraine headache Meningitis Temporomandibular joint dysfunction
Atelectasis Explanation: 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 membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.
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? Endocarditis Bronchitis Atelectasis Tuberculosis
In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? Superficial to the sternomastoid In front of the ear In the midline, a few centimeters behind the tip of the mandible At the angle of the mandible
Bleeding Explanation: Patients with acute head injuries and neurological changes must be quickly and accurately assessed by the health care team. Stabilization of the head and neck is essential to avoid further neurological injury. Any history of trauma to the head, neck, or both warrants a careful assessment of these structures for bleeding, swelling, loss of mobility, or pain.
The nurse in an emergency department is caring for a minimally responsive 27-year-old victim of a motorcycle accident. The client was not wearing a helmet. When assessing the client's head and neck, the nurse should prioritize the assessment for which of the following? Strain Cyanosis Pallor Bleeding
This could be a sign of cancer Explanation: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.
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 This could be a sign of pneumothorax This could be a sign of an embolus This could be a sign of a parotid stone
Mask-like expression Explanation: A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess? Sunken face Drooping of one side Mask-like expression Asymmetry of earlobes
Encourage the use of safety equipment Explanation: Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.
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 Encourage proper nutrition to promote healing Encourage the client to take a safety course Teach proper posture, bending, and lifting
C7 Explanation: 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.
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? C1 C3 C5 C7
Carotid artery Explanation: 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.
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? Internal jugular vein Carotid artery External jugular vein Temporal artery
a metastasis Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 12: Head and Neck, with Basic Vision and Hearing Basics, p. 303.
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of a metastasis tonsillitis nasopharyngitis a goiter
preauricular Explanation: The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? submental preauricular supraclavicular superficial cervical
On each side between the top of the ear and the eye Explanation: The temporal artery is located between the top of the ear and the eye. The submandibular glands are located inferior to the mandible, underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The internal jugular and carotid arteries are located bilaterally, parallel and anterior to the sternomastoid muscle.
The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location? On each side of the client's face, anterior and inferior to the ears On each side between the top of the ear and the eye Bilaterally, parallel to and anterior to the sternomastoid muscle Inferior to the lower jaw beneath the client's tongue
Inferior to the mandible beneath the tongue Explanation: The submandibular glands are located inferior to the mandible underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location? On each side of the client's face, anterior and inferior to the ears On each side between the top of the ear and the eye Bilaterally, parallel to and anterior to the sternomastoid muscle Inferior to the mandible beneath the tongue
Cranial nerve VII Explanation: Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.
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 V Cranial nerve VI Cranial nerve VII Cranial nerve VIII
Explanation: The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid muscle and medial to the midline of the neck.
The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?
Accessory (XI) Explanation: The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) nerves are involved with eye muscle movement. The hypoglossal (XII) nerve is involved with tongue muscles.
The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve? Abducens (VI) Accessory (XI) Hypoglossal (XII) Trochlear (IV)
hyperthyroidism Explanation: The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.
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 thyroid cyst Hashimoto thyroiditis benign tumor
Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delineation, mobility, consistency, and tenderness.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Congruency, induration, size, turgor Delineation, integrity, shape, color Consistency, delineation, mobility, tenderness Configuration, discreteness, temperature, color
Cup of water Explanation: When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. A cup of water would aid in swallowing. A penlight, tongue depressor, or ruler is not needed.
When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available? Penlight Tongue depressor Centimeter-scale ruler Cup of water
Hearing acuity Explanation: A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first? Hearing acuity Thyroid gland Mental status Lymph nodes
Auscultation Explanation: A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in 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, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? Inspection Palpation Auscultation Percussion
Open the mouth Explanation: 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.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Open the mouth Sit upright Sit without moving Perform a chewing action
Nodularity Explanation: If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes.
Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities? Nodularity Tenderness Enlargement Bruits
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.
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? Diabetes Brain tumor Impending stroke Hyperthyroidism
