Exam 2 Assessment

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

Where is the temporal artery palpated?

A. Above the cheek bone near the scalp line

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?

A. Acute infection

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?

A. Atelectasis

A nurse has performed a head and neck assessment of an adult patient and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

A. Document this as an expected assessment finding

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?

A. Encourage the use of safety equipment

Primary headaches are more worrisome than secondary headaches.

A. False

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 nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition?

A. 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?

A. Migraine headache

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?

A. Previous injuries to the head and neck

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

assessing for suspicious skin lesion and warning signs

Asymmetry Border Color Diameter: 1/8-1/4 inch Elevated warning signs: bleeding, tender to touch, itching, grows

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

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?

B. Arthritic changes of the cervical spine

What is the most common type of hyperthyroidism?

B. Grave's Disease

A client presents to the health care clinic with reports of a 12-pound unintentional 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 provider. What nursing diagnosis can the nurse confirm from this data?

B. Health Seeking Behaviors

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

B. Meningitis

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

B. Modes of transportation are the leading cause

A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?

B. Nasolabial folds

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

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

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

C. Acromegaly

A client suffering from a headache complains of throbbing, severe, unilateral pain that feels worse when exposed to bright lights. The client also complains of nausea and vomiting. What is the nurse's best action?

C. Administer migraine medication

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?

C. C7

When documenting the findings from a physical examination of the head and neck, what will the nurse include when describing the client's head?

C. Hair color

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

C. In the midline, a few centimeters behind the tip of the mandible

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

C. migraine headache.

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

C. tension headaches. Tension headaches are dull, tight, and diffuse.

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

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?

D. Impending Stroke

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

D. 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 for the asymmetry of the earlobes is what condition?

D. Parotid enlargement

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?

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

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

D. This could be a sign of cancer .

Vesicle/ Bulla

Elevated mass; contains serous fluid (chicken pox)

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

Cyanosis

O2 deficiency, white/blue tinged. dark skin appears blue/dull

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

Patch

Vitiligo. >1 cm

purpuric lesion:

cause by blood flowing out of breaks in the vessels. difficult to see in dark skinned people.

annular

circular lesions

purpura

confluent and extensive patch of petechia and ecchymoses. >3 mm. flat, red to purple, macular hemorrhage.

Wheal

elevated mass with irregular borders (uticaria). hives

Nodule

elevated palpable,

cyst

encapsulated fluid filled/semisolid in SQ tissue or dermis

confluent- smaller lesions run together to form larger lesionsMacule

freckle. <1 cm

Melanoma:

greatest risk is intermittent sun exposure

Sebaceous gland?

hair follicle, on all body besides palms/sole

apocrine sweat glands?

hair follicles/ perineum

Pt teaching for protecting against skin cancer:

hates, long sleeves, avoid sun burns, annual cancer screenings

discrete

individual and distinct ones

clustered

lesions grouped together- herpes

scar/fissure

linear crack, chapped lips/athletes foot

Acanthosis Nigrican

linear streak like pattern in dark skin people, suggests DM. roughening of skin on back of neck

hematoma:

localized collection of blood- associated with trauma

pallor

loss of color, cold skin (amenia)

Basal Cell Carcinoma:

moderate exposure (trunk/lower legs)

what type of lighting is best to use when assessing

natural light

Squamous cell carcinoma:

on body sites most common to heavy sun exposure

eccrine sweat glands?

over skin, normal sweat

cherry angioma:

papular and round

Plaque

psoriasis. >.5 cm.

pustule

pus filled vesicle (acne)

ecchymosis

round or irregular macular lesions seen with trauma. black eye

petechia

round red or purple macule 1-2 mm; associated. don't blanch. can be caused my meds

erosion:

scratch mark

Braden Scale:

sensory perception, moisture, activity, mobility, nutrition, friction/shear. 1 is a problem, 3 having no problem

ulcer

skin lost past epidermis

Erythema

skin redness/warmth, on dark skin palpate for warmth

linear lesion

straight line, scratch

What increases the risk for skin cancer?

sun exposure, fair skin, males (>50), HPV, etoh, inadequate niacin in diet.

What is the dermis?

thin layer, containing collagen, elastic tissue

Papules

wart. <.5 cm

Jaundice

yellow skin bc hepatic dysfunction (fix is UV light). normal in newborn 3-4th day of life