Chapter 15: Assessing Head and Neck

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. Explanation: Temporal arteritis is a painful inflammation of the temporal artery. Clients report severe unilateral headache sometimes accompanied by visual disturbances. This condition needs immediate care. A biopsy may be necessary for diagnosis; however the healthcare provider immediately. The temporal artery pulse can be palpated; but the carotid artery pulses should never be palpated simultaneously so that the client does not pass out from lack of blood flow to the brain.

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 Explanation: Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.

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 Explanation: Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.

When assessing a client with Graves disease, how would you expect the thyroid gland to be?

Soft Explanation: Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.

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 Explanation: The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.

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 Explanation: A sudden, severe headache with no known cause may be a sign of impending stroke, particularly if accompanied by sudden trouble seeing in one or both eyes or sudden trouble walking, dizziness, and loss of balance or coordination. Only impending stroke is associated with all of these symptoms. Diabetes is not associated with headache or the other symptoms. A tumor-related headache is aching and steady and not necessarily associated with sudden onset. Hyperthyroidism is associated with goiter(big mass), bruit(sound from mass), and sudden weight loss, but not with any of the symptoms listed.

A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?

tension Explanation: Tension headaches often arise in the temporal areas. Cluster headaches typically occur behind the eyes. A throbbing, severe, unilateral headache that lasts 6-24 hours and is associated with photophobia, nausea, and vomiting suggests a migraine headache. Hypertensive is not a type of headache although individuals with hypertension may experience a headache upon arising in the morning.

Where is the temporal artery palpated?

Above the cheek bone near the scalp line Explanation: The nurse palpates the temporal artery in the space above the cheek bone near the scalp line. The temporal artery is not found at midline at the base of the neck, between the mandibular joint and the base of the ear, or just left or right of the spine at the base of the skull.

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. Explanation: The third leading cause of traumatic brain injury is motor vehicle crashes. When instructing a group of adolescents on ways to prevent traumatic brain injuries, the most important thing for the nurse to include would be to always use seat belts. Wearing nonslip shoes in the house is a more appropriate teaching point for adults over 65 years of age. Instead of teaching adolescents to avoid risky activities such as snowboarding; they should be reminded to always wear a helmet. Adolescents should not be encouraged to use firearms. Instead, they should ensure that the responsible adult has stored the bullets and firearm in separate locations.

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

Aortic insufficiency Explanation: An involuntary nodding movement may be seen in clients with aortic insufficiency. Neurologic disorders may cause a horizontal jerking movement. Head tilted to one side may indicate unilateral vision or hearing deficiency or shortening of the sternomastoid muscle. Acorn-shaped, enlarged skull bones are seen in Paget's disease of the bone.

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 Explanation: Arthritic changes in cervical spine may present in the older adults as neck pain, decreased strength and sensation of the upper extremities. Bacterial thyroiditis has neck swelling and cranial damage may manifest as headaches or tension of the muscles

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?

Atelectasis Explanation: Atelectasis Complete or partial collapse of a lung or a section (lobe) of a lung can cause the trachea to be pushed to one side from its midline position. Endocarditis is an infection in the muscle of the heart, which does not cause the trachea to shift. Bronchitis is an inflammation of the mucous membrane of the bronchial tubes. Tuberculosis is an infection in the lungs. Neither bronchitis nor tuberculosis is responsible for the tracheal shift.

A nurse palpates 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 lobes Explanation: If a nurse palpates an enlargement of the thyroid, auscultation should be performed with the bell of the stethoscope to assess for the presence of a bruit. A bruit is a soft, swishing sound produced because of an increase in blood flow through the thyroid arteries. The nurse should also ask the client about past history of thyroid problems, the findings must be documented, then the health care provider notified once assessment is complete to obtain further orders.

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

Bell's palsy Explanation: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pains that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporomandibular joint syndrome causes pain or crepitation with jaw movement.

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?

Bruit Explanation: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. A murmur is assessed during a cardiac assessment.

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?

C7 Explanation: The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.

Correct response: What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.)

Correct response: The sternomastoid The mandible The midline of the neck Explanation: The anterior triangle is bordered by the mandible above, the sternomastoid laterally, and the midline of the neck medially.

migraine

Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.

A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider,

Fixed to underlying tissue Explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.

What is the most common type of hyperthyroidism?

Graves' disease Explanation: Graves' disease, the most common type of hyperthyroidism, is autoimmune and may also be genetic. Cushing's syndrome, moon face, and thyroid cancer are not the most common types of hyperthyroidism.

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.

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. Explanation: After thyroidectomy, clients must be treated with exogenous thyroid hormone for the rest of their lives. Thyroid hormones are usually taken by mouth on a daily basis.

An older adult client is admitted to the hospital after a fall during which the client's head was injured. While performing the admission assessment, the nurse finds a large ecchymosis over the C7-T1 area. The client reports tenderness on palpation and movement. What would be an appropriate nursing diagnosis for this client?

Impaired comfort related to possible neck injury Explanation: Diagnosis of a cervical spine injury is challenging and, in many cases, goes undiagnosed, especially in those lacking adequate health insurance. Clients at risk include those following a fall or collision and those with osteoporosis, advanced arthritis, cancer, or degenerative bone disease. The scenario does not indicate that the client is on bed rest or that the client has a limited range of motion.

The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes?

In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.

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 Explanation: Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting. Tension headaches are dull, tight, and diffuse.