Chapter 15
A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching? A. I must take thyroid hormone replacement medication for the rest of my life. B. I will complete the entire course of thyroid hormone replacement over six weeks. C. I must keep my follow up appointments to receive my thyroid hormone injections. D. I will take my thyroid hormone replacement medication once every week.
I must take thyroid hormone replacement medication for the rest of my life.
A client with a cervical spine injury has chronic pain. What would be the most appropriate initial nursing intervention for this client? A. Work with medical team to evaluate possible surgery B. Discuss pharmacologic interventions C. Chronic pain related to cervical spine injury D. Assess characteristics
Assess characteristics
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
Attempting to roll the structure up and down and side to side
A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use? A. Inspection B. Palpation C. Auscultation D. Percussion
Auscultation
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? Cardiovascular Integumentary Respiratory Nervous
Cardiovascular
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? A. Inspection B. Palpation C. Auscultation D. Percussion
Auscultation
Which of the following clients is most likely to be diagnosed with migraine headaches? A. A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room B. A woman who complains of recurrent headaches near the end of her workday spent at a computer station C. A man who has sought care for treatment of his episodic headaches that occur several times each day D. A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
A woman whose headaches come on suddenly and are somewhat relieved by a quiet, dark room
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 client's blood pressure.
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
Auscultate with the bell over the lateral lobes
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? A. Effects of age-related changes B. Brain tumor C. Hyperthyroidism D. Hypothyroidism
Hypothyroidism
Where is the temporal artery palpated? A. Above the cheek bone near the scalp line B. Just left of midline at the base of the neck C. Between the mandibular joint and the base of the ear D. Just left or right of the spine at the base of the skull
Above the cheek bone near the scalp line
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? A. Endocarditis B. Bronchitis C. Atelectasis D. Tuberculosis
Atelectasis
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? A. Endocarditis B. Bronchitis C. Atelectasis D. Tuberculosis
Atelectasis
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? A. Cranial nerve V B. Cranial nerve VI C. Cranial nerve VII D. Cranial nerve VIII
Cranial nerve VII
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? A. Myxedema B. Cushing's syndrome C. Scleroderma D. Bell's palsy
Cushing's syndrome
A nurse has performed a head and neck assessment of an adult patient 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 patient to the primary care provider promptly Perform a focused endocrine assessment Position the patient supine and reattempt palpation
Document this as an expected assessment finding
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? A. Encourage the use of safety equipment B. Encourage proper nutrition to promote healing C. Encourage the client to take a safety course D. Teach proper posture, bending, and lifting
Encourage the use of safety equipment
Primary headaches are more worrisome than secondary headaches.
False
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 consistency C. Fixed to underlying tissue D. Round and 8mm in size
Fixed to underlying tissue
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. Fixed to underlying tissue D. Round and 8 mm in size
Fixed to underlying tissue
On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems would the nurse want to rule out? A. A tumour B. Hypothyroidism C. Graves' disease D. Nephrotic syndrome
Graves' disease
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? A. Increased heart rate B. Increased blood pressure C. Laboratory tests D. Feeling anxious
Laboratory tests
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do? A. Assess for meningitis B. Look for involvement of other regions of the body C. Look for a source such as infection in the area that it drains D. Assess for dietary changes
Look for a source such as infection in the area that it drains
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.) Female gender Male gender Coffee drinker Tobacco use Age older than 50 years
Male gender Tobacco use Age older than 50 years
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? A. Migraine headache B. Meningeal inflammation C. Trigeminal neuralgia D. Parkinson's disease
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? A. Notify the healthcare provider immediately. B. Administer intravenous pain medication. C. Palpate the carotid pulses bilaterally at the same time. D. Prepare the client for a temporal artery biopsy.
Notify the healthcare provider immediately.
Where should a nurse place the hands to palpate the submandibular lymph nodes? A. On the medial border of the mandible B. At the angle of the mandible on the anterior edge C. At the posterior base of the skull bone D. A few centimeters behind the tip of the mandible
On the medial border of the mandible
Upon inspection of a client with reports of a fever, the nurse notices that the client's earlobes are asymmetrical in appearance. The nurse recognizes that the most common cause for the asymmetry of the earlobes is what condition? Bell's palsy Acute pharyngitis Thyroid enlargement Parotid enlargement
Parotid enlargement
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? A. Previous injuries to the head and neck B. Difficulty with swallowing C. Changes in sleeping habits D. Stiffness in the right shoulder
Previous injuries to the head and neck
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. Range of motion of the neck B. Headache C. Shortness of breath D. Range of motion of the arms and shoulders
Range of motion of the neck
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? A. Sternocleidomastoid B. Trapezius C. Masseter D. Temporalis
Sternocleidomastoid
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate? Tension pneumothorax Cardiac tamponade Flail chest Severe neck fracture
Tension pneumothorax
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? A. Noted anatomists B. The underlying bones C. Their anatomical positions D. The underlying vascular network
The underlying bones
The nurse is conducting a physical examination of a client who reports finding a lump in the neck. Which of the following questions should be included in when the nurse is collecting subjective data? (Select all that apply). A. When did you first notice the lump? B. How recently have you consumed alcohol? C. Do you have family members that experience lumps? D. Has the lump changed? E. Is it painful to touch?
When did you first notice the lump? How recently have you consumed alcohol? Has the lump changed?
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 A. explain to the client why the assessment is necessary. B. ask the client if touching the head is permissible. C. determine whether the client desires a family member present. D. examine the lymph nodes of the neck before examining the head.
ask the client if touching the head is permissible.
A nurse asks the client to describe the pain associated with a headache by rating the pain on a scale from 1 to 10. This subjective data should be documented in which section of the assessment? A. characteristic symptoms B. associated manifestations C. relieving factors D. location
characteristic symptoms
A client has an edematous face, hands, and legs. Which health problem should the nurse suspect this client is experiencing? scleroderma hypothyroidism hyperthyroidism Cushing's syndrome
hypothyroidism
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? A. malignancy B. inflammation C. enlargement D. hypothyroidism
malignancy
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
mediastinal mass atelectasis pneumothorax goiter
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Ask the client to: A. open the mouth B. sit upright C. sit without moving D. perform a chewing action
open the mouth
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an enlarged thyroid. lymph node abscess. neurologic disorder. parotid gland enlargement.
parotid gland enlargement.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? A. submental B. preauricular C. supraclavicular D. superficial cervical
preauricular
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? red cheeks mask-like face swelling around the eyes elongated prominent forehead
red cheeks
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? A. onset B. location C. treatment D. relieving factors
relieving factors
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? A. cluster B. tension C. migraine D. hypertensive
tension
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? A. Metastatic disease B. Chronic infection C. Acute infection D. Cushing's disease
Acute infection
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
Administer migraine medication
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? A. Arthritic changes of the cervical spine B. Bacterial thyroiditis C. Cranial damage D. Muscle tension
Arthritic changes of the cervical spine
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? A. Meningeal inflammation B. Stress C. Injury to the sternomastoid D. Arthritis
Arthritis
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? A. Avoid asking the client to remove her clothes for the examination B. Have a nurse who is the same sex as the client perform the examination C. Ask permission before palpating the head and neck D. Palpate the client's feet before palpating the head
Ask permission before palpating the head and neck
The nurse suspects an enlarged thyroid in a patient during the physical examination of the head and neck. What should the nurse first? Displace the trachea to the right. Listen over the thyroid with a stethoscope. Ask the patient to sip and swallow water. Ask the client to lie down for further assessment
Ask the patient to sip and swallow water.
A client with a cervical spine injury has 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 Chronic pain related to cervical spine injury Assess characteristics
Assess characteristics
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. Immediately notify the health care provider B. Document the findings in the nurse notes C. Auscultate with the bell over the lateral lobes D. Ask the client about past history of hypothyroidism
Auscultate with the bell over the lateral lobes
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. Sclera color B. Hair color C. Nasal mucosa color D. Facial skin color
Hair Color
What structure is found midline in the tracheal area just beneath the mandible? A. Cricoid cartilage B. Hyoid bone C. Thyroid cartilage D. Adam's apple
Hyoid bone
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order? A. Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus B. Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone C. Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid D. Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid
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. Tension B. Migraine C. Cluster D. Analgesic rebound
Tension
The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? A. Its position just below the mandible B. The curve on its inferior edge C. Its relation to the cricoid cartilage D. The notch on its superior edge
The notch on its superior edge
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. migraine headache. B. cluster headache. C. tension headache. D. tumor-related headache.
tumor-related headache.