Chapter 15- Assessing Head and Neck Prep U
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
parotid gland enlargement. Asymmetry in front of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
While assessing an older adult client's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should
refer the client to a physician for further evaluation. The trachea may be pulled to the affected side in cases of large atelectasis, fibrosis or pleural adhesions. The trachea is pushed to the unaffected side in cases of a tumor, enlarged thyroid lobe, pneumothorax, or with an aortic aneurysm.
During a physical examination of the head and neck, a client reports frequently feeling cold. What additional questions should the nurse ask for more information about the client's symptoms? (Select all that apply.)
"Do you dress more warmly than other people?"Do you use more blankets that others at home?"Do you perspire less than others?"
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 Take care to consider cultural norms for touch when assessing the head. Some cultures (e.g., Southeast Asian) prohibit touching the head or touching the feet before touching the head. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.
When assessing an adult client experiencing diarrhea, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What is the possible cause of these signs?
Cushing's syndrome Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigracans). The scenario does not describe signs and symptoms demonstrated by a client with myxedema, scleroderma, or Bell's palsy.
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? -Meningeal inflammation -Stress -Injury to the sternomastoid -Arthritis
Arthritis Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
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?"" To assess manifestations associated with the lump in the neck, the nurse would ask if the patient has difficulty swallowing. Asking how long the client has experienced discomfort from the lump is associated with duration. Asking when the patient first noticed the lump assesses the onset of the lump. Asking if there is there more than one lump assesses the location of the lump.
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 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
A nurse palpates a client's cervical lymph nodes and notes the following findings: cervical lymph nodes .6 inches (1.5 cm) in diameter (enlarged), painful, and mobile. What is the best action of the nurse?
Ask the client if they have experienced any other signs or symptoms. Normally, lymph nodes are either not palpable or they may feel like very small beads. If the nodes become overwhelmed by microorganisms, as happens with an infection such as mononucleosis, they swell and become painful. Lymph nodes greater than 6 inches (1.5 cm) in diameter is an abnormal finding and requires further assessment. If cancer metastasizes to the lymph nodes, they may enlarge but will not be painful. The nurse would further assess the client for other signs or symptoms before notifying the health care provider.
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. The first step would be for the nurse to assess characteristics of the pain. Surgery or pharmacologic interventions would be considered by the whole health care team after more information was gathered. While education is an appropriate intervention, it would not be addressed initially but rather after pain management interventions were implemented.
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. Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles?
Attempting to roll the structure up and down and side to side While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.
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 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.
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 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? a) C1 b) C3 c) C7 d) C5
C7 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.
A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?
Cluster headache Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
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 Nurses encourage use of appropriate safety equipment to reduce risk of head or neck trauma. There is no identified need to encourage proper nutrition to promote healing in this client. There is no identified need to teach proper posture, bending, and lifting with this client. Encouraging the client to take a safety course is not the primary focus of discharge teaching.
An anatomy and physiology instructor is discussing the lymphatic system of the head and neck. Why would the instructor emphasize the importance of the drainage pattern of the lymph?
Enlargement of a node may be a sign of pathology that is distant from that node. It is important to understand the drainage patterns of the lymphatics because enlargement of a node may be a sign of pathology that is not directly adjacent to that node.
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 The Headache Impact Test may be used to assess the impact of headache on a client's activities of daily living. A mnemonic assessment tool is used to assess for the character, onset, location, duration, severity, pattern, and associated factors of pain. It does not assess for the effect of pain on the client's activities of daily living. Auscultation is use of a stethoscope to assess the client's blood pressure, heart sounds, or respiration. The family health history portion of the interview is used to assess for health conditions of family members that might help shed light on the client's chief complaint.
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone Important landmarks for the head and neck region are in the tracheal area. The usually palpable U-shaped hyoid bone is located midline just beneath the mandible. The large thyroid cartilage consists of two flat, plate-like structures joined together at an angle and with a small, sometimes palpable notch at the superior edge. Usually more prominent in males, the thyroid cartilage is also called the "Adam's apple." The palpable cricoid cartilage is a ringed structure just inferior to the thyroid cartilage.
When identifying the midline structures of the neck from the mandible to the sternal notch, the nurse notes the structures in what order?
Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid The midline structures of the neck include (1) the mobile hyoid bone just below the mandible; (2) the thyroid cartilage, readily identified by the notch on the superior edge (larger in males than in females); (3) the cricoid cartilage; (4) the tracheal rings; and (5) the thyroid gland.
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?
Meningeal inflammation Meningeal inflammation is a likely cause of this condition, which manifests as sudden headache, neck pain with stiffness, and fever. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to noise or light, not by fever and neck stiffness. Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Parkinson's disease is not manifested by headache and neck pain.
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. 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.
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? a) Thyroid enlargement b) Acute pharyngitis c) Bell's palsy d) Parotid enlargement
Parotid enlargement Earlobe asymmetry can be due to parotid gland enlargement caused by an abscess or tumor. Bell's palsy is a neurologic condition that may cause drooping of one side of the face. Acute pharyngitis causes swelling in the throat, which is not usually visible on the outside of the face. Thyroid enlargement affects the neck and has no effect on the symmetry of the earlobes
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?
Perform a focused assessment Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.
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?
relieving factors Relieving factors includes anything the client subjectively reports they have tried to make the migraine go away. Onset refers to when the migraine started. Location helps determine what part of the client's head the pain is localized within or where it radiates. Treatment refers to any assessment, support, or care the client has received from various health care providers.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
tension 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.
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 This is a description of a typical tension headache.
A client reports sharp, shooting, piercing facial pains that last from seconds to minutes. The nurse identifies these as signs and symptoms of which of the following disorders
tic douloureux Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the divisions of the fifth trigeminal cranial nerve (the ophthalmic, maxillary, and mandibular areas). Signs and symptoms of hyperthyroidism include goiter, increased heart rate and blood pressure, increased appetite, loss of weight, heat intolerance. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. A stroke may cause a facial droop that is not painful.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth While performing the assessment of the temporomandibular joint, the nurse should ask the client to open the mouth. This gives an easy access to the joint. Telling the client to sit upright and not move helps in performing the overall examination; however, it does not contribute to the examination of the temporomandibular joint. Telling the client to perform a chewing action is not appropriate
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
Stiff neck Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
The underlying bones Regions of the head take their names from the underlying bones of the skull, not from the names of anatomists, anatomical positions, or vasculature.
The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of
a metastasis
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 Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.
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 The hallmarks of migraine headaches include a rapid onset, nausea, and relief by the removal of light and sound stimuli. Sustained muscle activity associated with typing and driving often precedes tension headaches. Cluster headaches, not migraines, are episodic over the course of a day.
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?
Acute infection The lymph nodes are enlarged and tender in acute infections. Normally, lymph nodes are not sore or tender and are usually not palpable. Chronic infection causes the nodes to become confluent. In metastatic disease, the nodes enlarge and become fixed in place and are nontender. The lymph node findings may vary in Cushing's disease
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 An involuntary nodding movement may be seen in patients 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 nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?
Document this as an expected assessment finding It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
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
The nurse assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? a) At the angle of the mandible b) In front of the ear c) In the midline, a few centimeters behind the tip of the mandible d) Superficial to the sternomastoid
In the midline, a few centimeters behind the tip of the mandible The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible
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
A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?
Notify the health care provider. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. These findings need to be reported to the health care provider immediately in order for steps to be taken that will determine the cause of the meningeal inflammation, for example, bacterial or viral meningitis. The nurse may administer acetaminophen for the pain, but this is not a priority. The nurse will document the findings and continue to monitor the client but notifying the health care provider is the priority action that is needed to ensure the safety of the client and others.
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 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.
During the physical examination of a 65-year-old client, the nurse finds that the pulsation of the temporal artery is weak. What is an appropriate action by the nurse for this client?
Recognize the weakened pulsation as an age-related change The nurse should consider the weakened pulse as an age-related change. The temporal arteries may have weak pulsation due to a decrease in the strength of the pulsation in old age. The nurse may check the blood pressure, but it is not the most appropriate action. The nurse may inform the physician, but the condition is not due to any underlying pathology. Decrease in the blood flow to the temporal artery will not affect the level of consciousness.
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?
arthritis Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
An adult client visits the clinic and tells the nurse that she has had headaches recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of a. cluster headaches b. migraine headaches c. tension headaches d. tumor-related headaches
cluster headaches
The nurse is preparing to assess a client's thyroid gland using the posterior approach. What direction should the nurse provide regarding the client's head?
flex the neck forward When assessing the thyroid gland from the posterior approach the client should flex the neck forward to relax the neck muscles. Tilting the head back would be used if assessing the thyroid gland using the anterior approach. Turning the head to the right or left shoulder would be done later in order to further assess the individual thyroid gland lobes.
A client reports slight swelling and tightness at the base of their neck. The nurse palpates the client's throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?
goiter The term used to describe an enlarged thyroid gland is goiter. A goiter may be seen in hyperthyroidism and hypothyroidism. Additional assessments will be required to determine the client's underlying condition causing the goiter, so it is not appropriate for the nurse to chart this finding as hyperthyroidism or hypothyroidism until further assessments are completed. Iodine deficiency is the primary cause of an enlarged thyroid gland, but such a deficiency has not yet been established, so it is not appropriate for the nurse to chart the finding as iodine deficiency.
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 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.
A nurse is about to receive a report on a 50-year-old female client diagnosed with Cushing syndrome. Which sign(s) and symptom(s) should the nurse expect? Select all that apply.
increased fat on the upper back increased facial hair round, puffy face thin extremities Cushing syndrome occurs when the adrenal cortex releases too much of the hormones cortisol, aldosterone, and sex hormones. This causes fluid and sodium retention (leading to a round, puffy face), potassium wasting, redistribution of fat (such as increased fat on the upper back, truncal obesity, and thin extremities), hyperglycemia, and hirsutism (deep voice and increased facial hair). Hypoglycemia is not associated with Cushing syndrome.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?
preauricular The lymph nodes in front of the ear, or preauricular, are usually palpated first. The submental nodes are under the chin. The supraclavicular nodes are located near the clavicle and sternocleidomastoid muscle. The superficial cervical nodes are located superficial to the sternocleidomastoid muscle.
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 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.
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
tumor related migraine Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
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 Atelectasis 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.
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 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, bruit, and sudden weight loss, but not with any of the symptoms listed.
Which type of vessels filter pathogens from the body and drain the fluid that has moved outside of the circulation back into the vessels?
Lymphatic Lymphatic vessels filter potential pathogens from the body. They also drain the fluid that has moved outside of the circulation back into the vessels. Arteries carry oxygenated blood from the heart to the body. Veins carry unoxygenated blood from the body to the lungs. Aortic is an adjective for aorta, which is the large vessel carrying oxygenated blood away from the heart.
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? a) Temporomandibular joint b) Nasolabial folds c) Preauricular nodes d) Earlobes
Nasolabial folds The nasolabial folds are ideal places to check facial features for symmetry. Inspection of the temporomandibular joint cannot elicit facial symmetry. Preauricular nodes are common head and neck lymph nodes that are not inspected but palpated. Earlobes are not an appropriate feature to use to determine facial symmetry
A 73-year-old woman comes to the office for evaluation of new onset of tremors. She is not taking any medications, herbs, or supplements. She has no chronic medical conditions. She does not smoke or drink alcohol. She walks into the examination room with slow, shuffling steps. She has decreased facial mobility with a blunt expression without any changes in hair distribution on her face. Based on this description, what is the most likely reason for the client's symptoms?
Parkinson's disease This is a typical description for a client with Parkinson's disease. Facial mobility is decreased, which results in a blunt expression or a "masked" appearance. The client also has decreased blinking and a characteristic stare with an upward gaze. Combined with the findings of slow movements and a shuffling gait, the diagnosis of Parkinson's is highly likely
A client is being admitted with a diagnosis of temporal arteritis. The nurse expects which of the following findings on assessment?
The temporal artery is hard, thick, and tender. An acute urgent condition is seen when the temporal artery is hard, thick, and tender with inflammation, as seen with temporal arteritis (inflammation of the temporal arteries that may lead to blindness). The temporal artery should be elastic and not tender. Sensitivity to light is not associated with temporal arteritis, but loss of vision may occur if not treated promptly. There is no asymmetry of the face with temporal arteritis.
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?
acromegaly Acromegaly is characterized by enlargement of the facial features (nose, ears) and the hands and feet. Parkinson disease is caused by decreased dopamine manifests with rigidity, bradykinesia, postural instability (slow, jerky movements), cogwheel gait, shuffling, and mask-like facies. Cushing syndrome may present with a moon-shaped face, reddened face, and increased facial hair. Scleroderma is an autoimmune disorder that can cause changes in the skin, blood vessels, muscles, and internal organs; skin may be tight and hard on the face and hands.
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?
red cheeks The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. A mask-like face is associated with Parkinson's disease. Swelling around the eyes is associated with nephrotic syndrome. An elongated prominent forehead is associated with acromegaly.
A client admitted to the hospital for a gastrointestinal bleed is now experiencing right-sided facial weakness. The nurse assesses the client and determines no other neurological deficits exist. The nurse determines the client is most likely exhibiting signs of which of the following disorders?
Bell palsy Signs and symptoms of Bell palsy include unilateral facial weakness (cranial nerve VII). Cranial nerve V (trigeminal) controls temporal and masseter muscles. Cranial nerve XII controls tongue movement. Trigeminal neuralgia involves cranial nerve V.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider?
Fixed to underlying tissue 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.
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?
Hypothyroidism Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.
