Chapter 15
Where is the temporal artery palpated? Above the cheek bone near the scalp line Just left of midline at the base of the neck Between the mandibular joint and the base of the ear Just left or right of the spine at the base of the skull
A
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 Bradycardia Headache
A, B, C
A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. lethargy constipation cool skin lower systolic blood pressure weight loss
A, B, C, D
The nurse assesses a client with noisy breathing including a gasping sound with respiration. The nurse notes tracheal deviation from the usual midline position. Which conditions should the nurse assess for further? Select all that apply. mediastinal mass atelectasis pneumothorax goiter inflammation of preauricular node
A, B, C, D
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? Tension Migraine Cluster Analgesic rebound
B
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? Ask the doctor for an order for an MRI Perform a focused assessment Prepare the client for a spinal tap Perform a generalized assessment
B
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 parotid gland enlargement. acromegaly. Paget disease. Cushing syndrome.
B
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
C
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
C
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? onset location treatment relieving factors
D
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
D
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
A
What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer
A
A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client? Migraine Meningitis Cervical fracture Measles
B
What activity is known to aggravate a tension headache? Listening to music Exercise Driving Prolonged sleep
C
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 Trapezius Masseter Temporalis
A
While the nurse is obtaining a client's health history regarding the head and neck, the client tells the nurse about having a lump in the neck. In order to assess for associated manifestations of this problem, which of the following questions should the nurse ask next? "Do you have difficulty swallowing? "How long have you experienced discomfort from the lump?" "When did you first notice the lump?" "Is there more than one lump?"
A
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism? Palpation of two or more enlarged parathyroid glands. Decreased serum calcium level on review of lab work. Unsymmetrical movement of thyroid gland when swallowing. Enlarged posterior portion of thyroid gland.
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? The boy requires assessment of his thyroid gland. There is an inflammatory response in the musculature of the boy's neck. The tissue underlying the nodes is infected. There is an infection in the area that these nodes drain.
D
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? Rush Gurgle Murmur Bruit
D
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
B
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
D
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
A
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.
A
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.
A
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
A
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
A
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. Wear nonslip shoes in the house. Avoid risky activities such as snowboarding Use of guns should be supervised by an adult
A
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
A
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 A woman who complains of recurrent headaches near the end of her workday spent at a computer station A man who has sought care for treatment of his episodic headaches that occur several times each day A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A
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? Migraine headache Meningeal inflammation Trigeminal neuralgia Parkinson's disease
B
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 explain to the client why the assessment is necessary. ask the client if touching the head is permissible. determine whether the client desires a family member present. examine the lymph nodes of the neck before examining the head.
B
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
C
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
C
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
C
he nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first? Displace the trachea to the right. Listen over the thyroid with a stethoscope. Ask the client to sip and swallow water. Ask the client to lie down for further assessment
C
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 cluster headaches. tumor-related headaches. migraine headaches. tension headaches.
D
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery. Discuss pharmacologic interventions. Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain.
D
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
D
When conducting a generalized assessment of a new client, what would the nurse focus upon when inspecting the neck? Signs of a strain Indications of a vertebral injury Lymph node enlargement Limitations in movement
D