Client Assesment PrepU Chapter 15 Assesing Head and Neck

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 seatbelts *third leading cause of traumatic brain injury: motor vehicle crashes. wearing nonslip shoes in the house is approapriate for viejitos (65 and up).

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 thryoid,

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.

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 heachache Migraine headache are usually located around the eyes, temples, cheeks, and forehead. Often accompanies by nausea and vommitting. Bells palsy is a one sides facial paralysis due to the inflammation of a facial nerve. Tension headache presents with stress, anxiety or tension and is located at the frontal temporal or occipital region Temporal arteritis produces pain around the temple but no nausea or vomiting

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.

The nurse prepares to assess the anterior triangle of a client's neck. Where should the nurse palpate this area on the diagram?

The anterior triangle is located in the area below the mandible, lateral to the sternocleidomastoid muscle and medial to the midline of the neck

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 in cervical spine may present with the older adults as neck pain, decreased strength and sensation of upper extremities. Bacterial thyroiditis has neck swelling and damage may manifest as head hurti or tension of the muscles

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.

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

ask the client if touching the head is permissible. *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.

A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next?

asses client's BP - 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.

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?

characteristic symptoms *characteristic symptoms include having the client rate the level of pain as this provides info bout severity, This subjective info is categorized as a characteristc info. Info about anything else that the client may be experiencing during the headache (like blurred vison) should be documented in associated manifestations. RElieving factors provide info about anything that the client has attempted to relieve symtoms. Locations provides subjective information about where headache is localized and pain radiates

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 asses manifestations associated with the lump of the neck, the nurse would as nect if the client has difficulty swallowing.

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

meningitis febrile is having fever Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.

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 previous injuries may cause limitations in movement and chronic pain

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent:

reduction of the blood supply to the brain. It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain.

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?

Bruits 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. - nosy blowin sound found in a vascular structure due to turbulence of blood flow could also be warning sign of stroke

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 about the thyroid gland? Select all that apply.

The thyroid gland is a large endocrine gland in the body. It produces thyroid hormones that increase the metabolic rate of most body cells. Consisting of two lateral lobes that curve posteriorly on both sides of the trachea and esophagus, it is mostly covered by the sternomastoid muscles. The parotid glands, not the thyroid, are located on each side of the face, anterior and inferior to the ears and behind the mandible. The submandibular glands, not the thyroid, produce saliva.

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.

A female client asks a nurse why it seems like her headaches are more severe and longer in duration than male friends who also have migraines. What is the best response by the nurse?

hormones affect the severity of migraine headaches - Women's migraines are often longer in duration than men's, and women report chronic pain more often. These differences can be caused by menstruation, hormonal changes, pregnancy, and menopause (Migraine Research Foundation, 2020). Although people experience different symptoms with migraines, this is not the best response to the client's question. Migraine severity is not related to genetics.

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, decreased sweating suggest hypothyroidism. Opposite symptoms, palpitations and involuntary weight loss suggest hyperthyroidism

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occurring more frequently. The nurse should refer the client for possible

trigeminal neuralgia trigeminal neuralgia (tic douloureux) is a manifested by sharp, shooting, piercing facial pains that last from seconds to minutes. Pain occurs over the division s of the fifth trigeminal cranial (ophthalmic, maxilalry, and mandibular areas)

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.

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

mandible explanation: the mandible (jawbone) provides the structural support for the floor and with the temporal bone, forms the temporomandibular joint (TMJ).

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 test may be used to assess the impact of headaches on clients adls. a mnmonic assessment toll is used to asses for the character onset location duration severity pattern and associated factors COLDSPA. 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.

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

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.

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 Adams apple. palpable cricoid cartilage is a ringed structure just inferior of thyroid cartilage

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

on medial border of mandible *submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle to the mandible on the anterior end of the sternomastoid muscle. The occipital nodes can be palpated at the posterior base of the skull bone. Submental lymph nodes can be palpated a few cm behind tip of mandible

The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to

Swallow a small sip of water *obseve the movement of the thyroid cartilage and thyroid gland

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 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 nurse is teaching nursing students about the risks associated with developing head and neck cancers. The nurse determines student understanding when the students make which of the following statements?

"Most head and neck cancers are linked to smoking." * Tobacco use increases the risk of head and neck cancer. Eighty-five percent of head and neck cancers are linked to tobacco use (smoking and smokeless tobacco). Alcohol use is also a risk factor for some head and neck cancers, but this is not the best option. Asbestosis has been found to contribute to head and neck cancers. Chewing tobacco can cause oral, throat cancers.

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

A mediastinal mass is any large mass of the lung, bronchi or pleural cavity, benign or malignant, that can cause a shift of the trachea from the normal midline position. Atelectasis refers to the diminished lung volume from either a blockage or inability to inflate the lungs fully. The decreased pressure associated with this problem could shift the trachea. Pneumothorax is a part or complete collapse of the lung due to abnormal air entry to the pleural space causing lung compression. This leads to little or no expansion of the lungs on inspiration. As a result, the trachea shifts. A goiter is an enlargement of the thyroid gland. The enlargement can impede upon the trachea shifting it from the midline position. The preauricular node is located in the front of the ear. Its location is not near the trachea.

The nurse in a community health clinic is preparing to assess the thyroid gland of a 22-year-old female client.

Position self to complete the assesment: behind the client Identify landmarks by palpation: identify thyroid and cricoid cartilages and thyroid isthmus displace the thyroid gland for palpation: ask client to swallow **Assessment of the thyroid gland can be performed by planning ahead and recognizing structures by palpation. Assessment of the thyroid gland can be done by standing behind the client or in front of the client. The thyroid gland is not assessed by standing to the left or right of the client. When beginning to assess the thyroid, three structures need to be identified by palpation: thyroid cartilage, cricoid cartilage, and thyroid isthmus. The other structures listed are not used as landmarks to assess the thyroid gland. When assessing the thyroid gland, the gland needs to be displaced. To do this, the client should be asked to swallow. Yawning and coughing will not displace the thyroid gland, which needs to be done to perform a thorough assessment.

Where is the temporal artery palpated?

Above the cheek bone near the scalp line the nurses palpates the temporal artery in the space above the cheekbone near the scalp line.

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?

cushings syndrome *Cushing's syndrome, excessive production of exogenous ACTH (adrenocorticotropic), 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.

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 an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first?

ask client to sip awa In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing which of the following disorders?

cerebrovascular accident Sudden trouble seeing or visual disturbances in one or both eyes or sudden trouble walking, dizziness, or loss of balance or coordination may be a sign of an impending stroke. Sudden weakness or numbness in the face, arms, or legs—especially on one side of the body—may indicate an impending stroke. Bell palsy affects cranial nerve VII, affects one side of the face, and is not painful. Temporal arteritis is an acute urgent condition 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). Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting, piercing facial pains that last from seconds to minutes.

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.

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.

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 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.