Chapter 15: Assessing Head and Neck
The nurse is conducting discharge teaching to the caregiver of an older adult who was hospitalized following a fall at home. Which statement by the caregiver indicates a need for additional teaching by the nurse?
"Changes in vision such as decreased accommodation happen with aging." "Certain medications can cause muscle weakness." "Loss of sensation in the toes is an age-related change." "Standing up slowly is important because dizziness can cause falls." Correct: "Loss of sensation in the toes is an age-related change."
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?
Assess for meningitis Assess for dietary changes Look for a source such as infection in the area that it drains Look for involvement of other regions of the body correct: Look for a source such as infection in the area that it drains
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 C5 C7 C3 Correct: C7
What is the most common type of hyperthyroidism?
Graves' disease Moon face Cushing's syndrome Thyroid cancer Correct:Graves' disease
The nurse is performing an assessment of the neck and identifies tracheal deviation. What is the most appropriate response of the nurse?
Palpate for thyroid Document findings Ask about recent injuries Notify the health care provider Correct: Tracheal deviation is an emergency and the health care provider should be notified immediately.
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 pneumothorax This could be a sign of a parotid stone This could be a sign of cancer This could be a sign of an embolus correct: This could be a sign of cancer
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
migraine headaches. tension headaches. cluster headaches. tumor-related headaches. Correct: tension headaches.
A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?
scleroderma Cushing syndrome acromegaly Parkinson disease Correct: acromegaly
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client?
Assess the client regarding characteristics of the pain. Educate the client regarding cervical spine pain. Discuss pharmacologic interventions. Work with medical team to evaluate possible surgery. Corrrect: Assess the client regarding characteristics of the pain.
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?
Assess the woman for hypothyroidism. Assess for other signs and symptoms of Cushing's syndrome. Order tests to rule out an overactive thyroid gland. Palpate the woman's parotid gland for enlargement. Correct: Assess the woman for hypothyroidism
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?
Cushing's disease Metastatic disease Chronic infection Acute infection Correct: Acute infection
Teenagers doing community service following arrest for driving under the influence and are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?
Fulfilling the court requirements Teaching them how to turn these clients every 2 hours Educating them about not drinking and driving Keeping the shelves restocked Correct: Educating them about not drinking and driving
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?
Have a nurse who is the same sex as the client perform the examination Avoid asking the client to remove her clothes for the examination Palpate the client's feet before palpating the head Ask permission before palpating the head and neck correct: Ask permission before palpating the head and neck
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?
Just above the thyroid cartilage Between the thyroid and the cricoid cartilages Just below the cricoid cartilage In front of the sternocleidomastoid muscle Correct: Just below the cricoid cartilage
A client arrives at the emergency room reporting drooping of one side of their face since early in the morning. The client denies pain and the face is asymmetrical with a left-sided droop. No other deficiencies such as weakness of the extremities or a change in gait are observed. What action should the nurse take?
Request a stat computed tomography scan to rule out a stroke. Discharge the client home because there are no other symptoms. Request a neurology consult to determine the cause of facial muscle weakness. Alert the rapid response team. Correct: Request a neurology consult to determine the cause of facial muscle weakness.
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 Analgesic rebound Cluster Migraine Correct: Migraine
The nurse is planning to instruct a group of adolescents on ways to prevent traumatic brain injuries. What should be included in these instructions?
Wear nonslip shoes in the house. Avoid risky activities such as snowboarding. Use of guns should be supervised by an adult. Always use seat belts. Correct: Always use seat belts.
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. Correct: ask the client if touching the head is permissible.
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 treatment relieving factors location Correct: relieving factors
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:
rapid rise in the client's pulse rate. premature ventricular heart sound. reduction of the blood supply to the brain. decreased pulse pressure. Correct: reduction of the blood supply to the brain.