Client assessment CH.15 Assessing Head and Neck

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 experience any other signs or symptoms.

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.

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

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

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?

Characteristics symptoms

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

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

What is the most common type of hyperthyroidism?

Graves' disease

When identifying the midline structures of the neck from the mandible to the sternal notch, the urse notes the structures in what order?

Hyoid bone , thyroid cartilage , cricoid cartilage , isthmus of the thyroid

While the nurse is assessing a client for an unrelated health concern, the client experiences a Jen, severe headache with no known cause. He also complains of dizziness and trouble ng out of one eye. What associated condition should the nurse suspect in this client?

Impending stroke

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 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?

Loss of sensation in the toes in an age-related change

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

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

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

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?

Migrane

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

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

Open the mouth

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

Reduction of blood supply to the brain.

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

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

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

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

A client reports slight swelling and tightness at the base of their neck. The nurse palpates the clients throat and neck and determines the thyroid gland is enlarged. What medical term will the nurse use when charting this finding?

goiter

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

sit in an upright position.

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

tension

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.

A large endocrine gland in the body produces hormones that increase the metabolic rate of most body cells consist of two lateral lobes covered mostly by the sternomastoid

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

While assessing an adult client's skull, the nurse observes that the client's skull and facial bones are larger and thicker than usual. The nurse should assess the client for

Acromegaly

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

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.

The client is having a thyroid crisis. What symptoms would the nurse assess for?

Tachypnea, Nausea and Anxiety Explaintion: Clients experiencing a thyroid crisis may present with tachpnea, tachycardia, nausea, vomiting, diarrhea, abdominal pain and anxiety. Neck swelling may be related to hypothyroidism or acute bacterial thyroiditis.