Chapter 15: Assessing Head and Neck

A female client describes headache symptoms to seem to indicate a migraine. Which of the following questions during the client interview would, if answered in the positive, tend to confirm the nurses suspicion ?

"Does the headache occur regularly with your menstrual cycle?"

A nurse is examining a client's goiter and explaining the characteristics and functions of the thyroid gland. Which of the following should the nurse mention? Select all that apply

- produces hormones that increase the metabolic rate of most body cells - covered mostly by the sternomastoid muscles - largest endocrine gland in the body -consists of 2 lateral lobes

A nurse palpates an enlarged, hard, and non tender left-sided supraclavicular lymph node in a client. Where should the nurse focus the physical assessment to obtain more data about this finding?

Abdomen and thoracic area for changes associated with malignancy

Upon examination of the head and neck of a client, a nurse notes that the submandiublar nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

While examining a client, the nurse observes that he appears to be nodding his head involuntarily. Which if the following conditions should the nurse additionally assess for, based on this findings?

Aortic insufficiency

An 81 year old client complains of neck pain and demonstrates decreased range of motion on examination.

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?

Ask permission before palpating the head and neck

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?

Atelectasis

A nurse palates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?

Auscultate with the bell over the lateral loves

A nurse is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?

Auscultation

While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The. Urge recognizes this as what condition?

Bell's palsy

The nurse is palpating a client's cervical vertebra. Which vertebrae can be easily palpated when the neck and should help the nurse locate the other vertebrae

C7

The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be specifically careful to avoid bilaterally compressing during the assessment?

Carotid artery

A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks.

Cluster

Which risk factor for traumatic brain injury (TBI) should a nurse include in a discussion about prevention for a group of adolescents?

Concussions in sports and motor vehicle accidents cause the largest number of TBIs in teens

A nurse performs palpating of a client's lump nodes. Which findings should be reported to the health care provider?

Fixed to underlying tissue

A nurse needs to examine a client's thyroid as pasty of the head and neck assessment. How should the nurse instruct the client to position his head to best facilitate this exam?

Flex the head towards the side being examined

A client presents to the health care clinic with reports of a stiff neck for the past 3 days. What objective information can the nurse obtain during the health history using inspection?

Head position

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?

Headache impact test

A client presents to the loath care clinic with reports of a 12- pound al weight loss despite being hungry all the time, profuse sweating, and swelling around the anterior neck area. The client states that she does not have insurance and cannot afford to see a regular health care providers. What nursing diagnosis can the nurse confirm from this data?

Health seeking behaviors

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?

Impending stroke

In reviewing a client's Howard history, the nurse notes that the client has had a history of TMJ use recognizes that which of the following bones is involved in this dysfunction ?

Mandible

A client presents to the emergency department with reports of neck pain and 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?

Meningeal inflammation

A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms?

Migraine headache

Which area should the nurse inspect for facial symmetry when performing a head and neck assessment?

Nasolabial folds

A. Jess needs to palpable a client's submandibular lymph modes. Where should the nurse place her hands to do this?

On the medial border of the mandible

Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?

Open the mouth

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 or the asymmetry of the earlobes is what condition?

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?

Previous injury to the head and neck

During the physical examination of a 60 year old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse form this client?

Recognize the weakened pulsation as an age-related change

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