Chapter 14 - Head, Face, Neck, and Regional Lymphatics

What are the facial structures that should appear symmetric when inspecting the head?

The eyebrows, eyes, ears, nose, and mouth appear about the same on both sides. The palpebral fissures—the openings between the eyelids—are equal bilaterally. Also the nasolabial folds—the creases extending from the nose to each corner of the mouth—should look symmetric.

Bruit

Soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally.

Major neck muscles

Sternomastoid and trapezius

Borders of 2 regions in the neck: the anterior triangle and the posterior triangle

- the sternomastoid divides each side of the neck into two triangles. - the anterior triangle lies in front, between the sternomastoid and the midline of the body, with its base up along the lower border of the mandible and its apex down at the suprasternal notch. - the posterior triangle is behind the sternomastoid muscle, with the trapezius muscle on the other side and its base along the clavicle below. It contains the posterior belly of the omohyoid muscle. - these triangles are helpful guidelines when describing findings in the neck.

What conditions are associated with parotid gland enlargement?

AIDS and Mumps.

Which is the least likely to indicate a possible malignancy? a. History of radiation therapy to the head, neck, or upper chest b. History of using chewing tobacco c. History of large alcohol consumption d. Marked tenderness

Answer : D Marked tenderness Cancerous lymph nodes are nontender. Marked tenderness may indicate an acute infection.

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. What area of the body will the nurse assess? a. At the level of the C7 vertebra b. At the level of the T11 vertebra c. At the level of the L5 vertebra d. At the level of the S3 vertebra

Answer: A At the level of the C7 vertebra The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

Which is true regarding cluster headaches? a. They may be precipitated by alcohol and daytime napping. b. Their usual occurrence is two per month, each lasting 1 to 3 days c. They are characterized as throbbing d. They tend to be supraorbital, retro-orbital, or frontotemporal.

Answer: A They may be precipitated by alcohol and daytime napping. Their usual occurrence is actually 1-2/day, each lasting 1/2 to 2h for 1 to 2 months, then remission for months or years. They're actually characterized as continuous, burning, piercing, excruciating (NOT throbbing) They're actually always one-sided, often retro-orbital or around the eye, temple, forehead, cheek

A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? a. Thyroid b. Parotid c. Adrenal d. Parathyroid

Answer: A Thyroid The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4. The parotid glands are salivary glands and secrete saliva. The adrenal glands secrete corticosteroids, not T4 The parathyroid glands control the body's calcium.

Bell palsy is characterized by: a. Unilateral paralysis of complete half of the face b. Bulging eyeballs c. A face that appears masklike d. A puffy, edematous face

Answer: A Unilateral paralysis of complete half of the face Bulging eyeballs occur in hyperthyroidism/Graves disease A face that appears masklike occurs with Parkinson Syndrome (a deficiency of the neurotransmitter dopamine and degeneration of the substantia nigra of the basal ganglia in the brain) A puffy, edematous face occurs with hypothyroidism/Myxedema

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

Answer: A Using gentle pressure, palpate with both hands to compare the two sides. Strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

The isthmus of the thyroid gland lies just below the: a. Mandible b. Cricoid cartilage c. Hyoid cartilage d. Thyroid cartilage

Answer: B Cricoid cartilage The thyroid gland straddles the trachea in the middle of the neck. The gland has two lobes, both conical in shape, each curving posteriorly between the trachea and the sternomastoid muscle. The lobes are connected by a thin isthmus. The neck cartilages are important landmarks for locating the thyroid gland. The thyroid cartilage has a small, palpable V in its upper edge (called "Adam's apple" in men). Beneath that is the cricoid cartilage or upper tracheal ring. Beneath the cricoid cartilage, the isthmus of the thyroid gland hugs the 2nd and 3rd tracheal rings.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

Answer: B Dehydration Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw. What does the nurse suspect? a. Inflammation of the thyroid gland b. Inflammation of the parotid gland c. Infection in the occipital lymph node d. Infection in the submental lymph node

Answer: B Inflammation of the parotid gland Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

When examining the face of a patient, what are the two pairs of salivary glands that are accessible for examination? a. Occipital; submental b. Parotid; submandibular c. Submandibular; occipital d. Sublingual; parotid

Answer: B Parotid; submandibular The parotid glands are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands are beneath the mandible at the angle of the jaw. The occipital and submental are lymph nodes, not glands The sublingual glands lie on the floor of the mouth, so are not readily accessible for examination.

The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. V b. VII c. XI d. XIII

Answer: B VII Cranial nerve VII is the facial nerve, which mediates Facial muscles; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). Cranial nerve V, the trigeminal nerve, mediates facial sensations of pain and touch. Cranial nerve XI is the spinal accessory nerve that innervates the sternomastoid and trapezius muscles of the neck. There is no cranial nerve XIII (only 12 cranial nerves).

The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? (Select all that apply.) a. Absent tonic neck reflex b. Nonpalpable cervical lymph nodes c. Fontanels firm and slightly concave d. Head circumference equal to chest circumference e. Head circumference less than chest circumference f. Head circumference greater than chest circumference

Answer: B, C, F An infant's head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been previously noticed. What does the nurse suspect? a. An iodine deficiency b. Early signs of goiter c. A normal enlargement of the thyroid gland during pregnancy d. Possible thyroid cancer and the need for further evaluation

Answer: C A normal enlargement of the thyroid gland during pregnancy The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. What should the nurse do? a. Check for the bruit again in 1 hour. b. Stop the examination, and notify the physician. c. Continue the examination because a bruit is a normal finding for this age. d. Notify the parents that a bruit has been detected in their child and requires further evaluation.

Answer: C Continue the examination because a bruit is a normal finding for this age. Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect? a. Bell palsy b. Scleroderma c. Damage to the trigeminal nerve d. Frostbite with resultant paresthesia to the cheeks

Answer: C Damage to the trigeminal nerve Facial sensations of pain or touch are mediated by CN V, which is the trigeminal nerve. Bell palsy is associated with CN VII damage. Frostbite and scleroderma are not associated with this problem.

Identify the blood vessel that runs diagonally across the sternomastoid muscle. a. Temporal artery b. Carotid artery c. External jugular vein d. Internal jugular vein

Answer: C External jugular vein

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? a. Clumped b. Unilateral c. Firm but freely movable d. Soft and nontender

Answer: C Firm but freely movable Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

On examination, the newborn's fontanels should feel: a. Tense or bulging b. Depressed or sunken c. Firm, slightly concave, and well defined d. Pulsating

Answer: C Firm, slightly concave, and well defined

The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck. a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

Answer: C Hydrocephalus Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or "setting sun" eyes are noted. Craniotabes is a softening of the skull's outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma.

The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located? a. Just below the hyoid bone and posterior to the tragus b. Just below the vagus nerve and posterior to the mandible c. Just below the temporal artery and anterior to the tragus d. Just below the temporal artery and anterior to the mandible

Answer: C Just below the temporal artery and anterior to the tragus

A throbbing, unilateral pain associated with nausea, vomiting, and photophobia is characteristic of: a. Cluster headache b. Subarachnoid hemorrhage c. Migraine headache d. Tension headache

Answer: C Migraine headache

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland? a. Behind with the nurse's hands placed firmly around his neck b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward d. The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward

Answer: C The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward Examining this patient's thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? a. XII; assess for a positive Romberg sign. b. XI; palpate the anterior and posterior triangles. c. XI; have patient shrug their shoulders against resistance. d. XII; percuss the sternomastoid and submandibular neck muscles.

Answer: C XI; have patient shrug their shoulders against resistance. The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To assess the function of cranial nerve XI the nurse should have the patient shrug their shoulders against resistance. Cranial nerve XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech and swallowing and is not involved in head movement. Identifying the anterior and posterior triangles are helpful guidelines when describing findings in the neck but palpating them does not assess any cranial nerves.

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond? a. "Perhaps that could be a result of your dietary intake during pregnancy." b. "Your baby may have craniosynostosis, a disease of the sutures of the skull." c. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." d. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

Answer: D "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life." Membrane-covered "soft spots" allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, what should the nurse assess? a. Infraclavicular area b. Supraclavicular area c. Area distal to the enlarged node d. Area proximal to the enlarged node

Answer: D Area proximal to the enlarged node When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion? a. Exophthalmos b. Bowed long bones c. Acorn-shaped cranium d. Coarse facial features

Answer: D Coarse facial features Acromegaly is the excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student? a. Head, breasts, groin, and abdomen b. Arms, breasts, inguinal area, and legs c. Head and neck, arms, breasts, and axillae d. Head and neck, arms, inguinal area, and axillae

Answer: D Head and neck, arms, inguinal area, and axillae Nodes are located throughout the body, but they are accessible to examination only in those 4 areas.

If the thyroid gland were enlarged bilaterally, which maneuver would be appropriate for you to assess? a. Check for deviation of the trachea b. Listen for a bruit over the carotid artery c. Listen for a murmur over the aortic area d. Listen for a bruit over the thyroid lobes

Answer: D Listen for a bruit over the thyroid lobes If the thyroid gland is enlarged, auscultate it for the presence of a bruit. This is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. The bruit is not present normally. A bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid (e.g., hyperthyroidism).

Which facial bones articulate at a joint instead of a suture? a. Zygomatic b. Maxilla c. Nasal d. Mandible

Answer: D Mandible

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40 C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

Answer: D Meningeal inflammation The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

Providing resistance while the patient shrugs his or her shoulders is a test of which cranial nerve? a. II b. V c. IX d. XI

Answer: D XI Test muscle strength and the status of cranial nerve XI (ACCESSORY NERVE) by trying to resist the person's movements with your hands as the person shrugs the shoulders and turns the head to each side. *CRANIAL NERVE XI has a purely somatic motor function, innervating the sternocleidomastoid and trapezius muscles

Compare Bell palsy with stroke

Bell palsy is a LOWER MOTOR NEURON lesion (PERIPHERAL) producing rapid onset of cranial nerve VII paralysis of facial muscles; almost always unilateral. This may be a reactivation of herpes simplex virus (HSV-1) latent since childhood. Note COMPLETE paralysis of one-half of the face; person CANNOT wrinkle forehead, raise eyebrow, close eyelid, whistle, or show teeth on the left side. Usually presents with smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and pain behind the ear. This is greatly improved if corticosteroids and antivirals are given within 72 hours of onset. Stroke/brain attack is an UPPER MOTOR NEURON lesion (CENTRAL). A stroke is an acute neurologic deficit caused by blood clot of a cerebral vessel, as in atherosclerosis (ischemic stroke), or a rupture in a cerebral vessel (hemorrhagic stroke). If you suspect a stroke, ask if the person can smile. Note paralysis of the lower facial muscles but also note that the UPPER HALF OF FACE IS NOT AFFECTED because of the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. Stroke requires emergency 9-1-1 treatment.

What should normal cervical nodes feel like upon palpation?

Cervical nodes often are palpable in healthy persons, although this palpability decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

Dysphagia

Difficulty swallowing

What are the characteristics of normal cervical lymph nodes during childhood?

During infancy cervical lymph nodes are not palpable normally. But a child's lymph nodes are—they feel more prominent than an adult's until after puberty, when lymphoid tissue begins to atrophy. Palpable nodes less than 3 mm are normal. They may be up to 1 cm in size in the cervical and inguinal areas but are discrete, move easily, and are nontender. Children have a higher incidence of infection, so you can expect a greater incidence of inflammatory adenopathy. No other mass should occur in the neck.

Lymphadenopathy

Enlargement of the lymph nodes (>1 cm) from infection, allergy, or neoplasm.

What are the characteristics of Graves disease (hyperthyroidism) and Myxedema (hypothyroidism)?

Graves disease (hyperthyroidism): - autoimmune disease with increased production of thyroid hormones causes an increased metabolic rate - - manifested by goiter, eyelid retraction, and exophthalmos (bulging eyeballs). - symptoms include nervousness, fatigue, weight loss, muscle cramps, and heat intolerance. - signs include forceful tachycardia; shortness of breath; excessive sweating; fine muscle tremor; thin silky hair; warm, moist skin; infrequent blinking; a staring appearance; and brisk ankle jerks. Myxedema (hypothyroidism): - deficiency of thyroid hormone - reduced the metabolic rate and, when severe, causes a nonpitting edema or myxedema. - usual cause is Hashimoto thyroiditis. - symptoms include fatigue and cold intolerance. - signs include puffy, edematous face, especially around eyes (periorbital edema); puffy hands and feet; coarse facial features; cool, dry skin; dry, coarse hair and eyebrows; slow reflexes; and sometimes thick speech.

What are the facial characteristics that occur with Down Syndrome?

Head and face characteristics of Down Syndrome (trisomy 21) may include upslanting eyes with inner epicanthal folds; flat nasal bridge; small, broad, flat nose; protruding, thick tongue; ear dysplasia; short, broad neck with webbing; and small hands with single palmar crease.

Torticollis

Head tilt due to shortening or spasm of one sternomastoid muscle

Neck examination

Inspect and palpate the neck - Active ROM - Enlargement of salivary glands, lymph nodes, thyroid gland - Position of trachea - Auscultate thyroid (if enlarged) for bruit

Head examination

Inspect and palpate the skull - General size and contour - Note any deformities, lumps, tenderness - Palpate temporal artery, temporomandibular joint

Face examination

Inspect the face - Facial expression - Symmetry of movement (cranial nerve VII-facial) - Any involuntary movements, edema, lesions

What are the characteristics of lymph nodes associated with acute infection, chronic inflammation, cancer, HIV, and Hodgkin lymphoma?

The following criteria are common clues but are not definitive in all cases: • Acute infection—acute onset, <14 days' duration; nodes are bilateral, enlarged, warm, tender, and firm but freely movable. • Chronic inflammation (e.g., in tuberculosis the nodes are clumped). • Cancerous nodes are hard (feel like a rock), >3 cm, unilateral, nontender, matted, and fixed to adjacent structures. • Nodes with HIV infection are enlarged, firm, nontender, and mobile. Occipital node enlargement is common with HIV infection. • A single enlarged, nontender, hard left supraclavicular node may indicate neoplasm in thorax or abdomen (Virchow node). • Painless, rubbery, discrete nodes that gradually appear occur with Hodgkin lymphoma, commonly in the cervical region.

Describe the tonic neck reflex in the infant

The infant can turn the head side to side by 2 weeks and shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months, and then the head is maintained in the midline. Head control is achieved by 4 months, when the baby can hold the head erect and steady when pulled to a vertical position.

What characteristics should you note when palpable nodes are found?

Their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness.

What's the difference between caput succedaneum and cephalhematoma in the newborn infant?

Two common variations in the newborn cause the shape of the skull to look markedly asymmetric: - CAPUT SUCCEDANEUM is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. It feels soft, and it may extend across suture lines. It gradually resolves during the first few days of life and needs no treatment. - CEPHALHEMATOMA is a subperiosteal hemorrhage, which is also a result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone because the periosteum (i.e., the covering over each bone) holds the bleeding in place. It appears several hours after birth and gradually increases in size. No discoloration is present, but it looks bizarre; parents need reassurance that it will be resorbed during the first few weeks of life without treatment. Rarely a large hematoma may persist to 3 months.

Goiter

enlargement of the thyroid gland (occurs with hyperthyroidism)