HA Assess. Head and Neck
A nurse is working with a client who has a history of headaches. When preparing to assess the client's temporomandibular joint (TMJ), the nurse should provide what instruction?
"I'm going to put my fingers in front of your ears and ask you to open your mouth wide." Explanation: To assess the TMJ, place your index finger over the front of each ear as you ask the client to open her mouth. None of the other listed instructions facilitates this assessment.
The nurse assesses the client's pulses to be normal. These would be documented how?
2+ Explanation: Normal pulses are 2+. Absent pulses are 0. Weak pules are 1+. Increased pulses are are 3+.
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. Explanation: Fatigue, weakness, and cold sensitivity are symptoms of hypothyroidism. These symptoms are not associated with Cushing's syndrome, hyperthyroidism, or any of the disorders that result in parotid gland enlargement.
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.
A nurse is assessing the head and neck of an adult client. Which vertebra should the nurse identify as a landmark in order to locate the client's other vertebrae?
C7 Explantion: The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark helps the nurse to locate other vertebrae.
A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?
Compressing the arteries bilaterally Explanation: The nurse needs to avoid bilateral compression of the carotid blood vessels to prevent reducing the blood supply to the brain. The nurse does not need to avoid having the client flex the neck, ask the client to swallow water, or perform the exam while the client is seated.
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?
Cranial nerve VII Explanation: Facial asymmetry may indicate inflammation of cranial nerve VII with Bell palsy.
A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which finding should the nurse attribute to age-related physiological changes?
Decreased strength of temporal artery pulsations Explanation: The strength of the pulsation of the temporal artery may be decreased in the older client. Enlargement of a single thyroid nodule suggests a malignancy and must be evaluated further. Carotid pulses should always be palpable in healthy clients, and tender lymph nodes are a pathologic finding in clients of any age.
Which of the following would put the client at risk for falls? Select all that apply.
Dizziness, Hypotension and Confusion Explanation: Dizziness, hypotension and confusion may put the client at risk for falls. Palpitations and diaphoresis does not increase fall risk.
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 Explanation: 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.
Primary headaches are more worrisome than secondary headaches.
False Explanation: Because a secondary headache has a serious underlying cause, it is more worrisome than a primary headache, and requires urgent attention.
After teaching a group of students about risk factors for traumatic brain injury, the instructor determines that additional teaching is needed when the students identify which of the following?
Female gender Explanation: Risk factors for traumatic brain injury include transportation accidents, violence (often firearms related), falls, male gender, failure to use protective equipment, and participation in contact sports.
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.
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 Explanation: While collecting history, the nurse would be able to inspect the client to see in what position the head was being held. Range of motion would require the nurse to give the client commands and would be performed during the physical assessment. Neck tenderness and thyroid size would require the use of palpation, not inspection, and would also be covered in the physical assessment portion of the examination.
The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what?
Hypovolemia Explanation: A weak pulse can indicate hypovolemia, shock or decreased cardiac output. Pulse inequality may indicate a constriction or occlusion. Hypervolemia would be manifested by bounding pulses.
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.
What nursing diagnosis would be most appropriate for a client admitted with heart failure?
Ineffective tissue perfusion Explanation: Heart failure can cause ineffective tissue perfusion which can lead to fatigue, pain and activity intolerance. Impaired gas exchange would be more appropriate for respiratory disorders
During a neck assessment, where would the nurse focus palpation of the thyroid isthmus?
Just below the cricoid cartilage Explanation: Just below the cricoid cartilage, the isthmus of the thyroid should be palpable as a smooth rubbery band that rises and falls with swallowing. The other three options are distracters for the question since none accurately describe the location of the isthmus.
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 Explanation: 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.
The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. What would the nurse most likely assess?
Mask-like expression Explanation: A client with Parkinson's disease often exhibits a masklike face. A sunken face with depressed eyes and hollow cheeks is typical of cachexia. Drooping of one side may suggest a stroke or Bell's palsy. Asymmetry of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
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?
Meningeal inflammation Explanation: 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 and 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 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 Explanation: 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 nurse is caring for a patient admitted with neck pain. The patient is febrile. What is the most likely medical diagnosis for this patient?
Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.
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?
Migraine Explanation: This is a description of a common migraine (no aura). Distinctive features of a migraine include phono- and photophobia, nausea, resolution with sleep, and unilateral distribution. Only some of these features may be present.
Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?
Nodularity Explanation: If palpable, the older adult's thyroid gland may feel more nodular or irregular because of fibrotic changes that occur with aging. The thyroid also may be felt lower in the neck because of age-related structural changes.
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 nurse needs to palpate a client's submandibular lymph nodes. Where should the nurse place her hands to do this?
On the medial border of the mandible Explanation: The submandibular lymph nodes can be palpated on the medial border of the mandibular bone. Tonsillar nodes are found at the angle of the mandible on the anterior edge 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 centimeters behind the tip of the mandible.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse?
Open the mouth Explanation: 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.
During a health history, a client reports complaints of headaches. What would lead the nurse to suspect that the client is experiencing cluster headaches?
Pain radiating from eye to temporal region Explanation: Cluster headaches are typically localized in the eye and orbit and radiate to the facial and temporal regions. Throbbing severe pain, reports of ringing in the ears prior to the headache, and sensitivity to light suggest migraine headache.
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?
Parotid enlargement Explanation: 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 nursing educator is evaluating a colleague's examination of a client's thyroid gland. The educator would determine that the nurse needs additional instruction when the nurse demonstrates which technique?
Percussion Explanation: When examining the thyroid gland, the nurse inspects for enlargement and asymmetry; auscultates for bruits; and palpates for tumors, masses, size, and tenderness. Percussion does not provide meaningful data.
A college student presents with a sore throat, fever, and fatigue for several days. Exudates are on her enlarged tonsils. A careful lymphatic examination reveals some scattered small mobile lymph nodes just behind her sternocleidomastoid muscles bilaterally. What group of nodes is this?
Posterior cervical Explanation: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.
A nurse is providing care at an inner-city shelter, and a man who frequents the shelter presents with a significant frontal growth that is located midline at the base of his neck. The nurse should recognize the need for what referral?
Referral for further assessment of thyroid function Explanation: A goiter (an enlarged thyroid gland) may appear as a large swelling at the base of the neck. This growth is not suggestive of impaired cranial nerve or lymphatic function, and it does not normally impair swallowing ability.
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 Explanation: The sternomastoid muscle rotates and flexes the head, whereas the trapezius muscle extends the head and moves the shoulders. The masseter and temporalis muscles are involved in raising and lowering the mandible during mastication (chewing).
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches?
Stiff neck Explanation: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
What finding upon assessment would indicate the client is experiencing shock?
Systolic blood pressure 50 Explanation: A systolic blood pressure of 50 would indicate the client is experiencing shock.
The client has been diagnosis with severe sepsis. Which finding would indicate the client is experiencing low cardiac output?
Tachycardia; hypotension Explanation: A low cardiac output would be exhibited by tachycardia and hypotension.
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 Explanation: This is a description of a typical tension headache.
A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?
Tension pneumothorax Explanation: Palpation of the thyroid gland reveals important landmarks of the trachea. Such landmarks are noted when assessing for tracheal deviation, which accompanies a potentially life-threatening condition called tension pneumothorax. A deviation of the trachea does not indicate cardiac tamponade, flail chest, or a severe neck fracture.
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 Explanation: 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 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?
This could be a sign of cancer Explanation: Lymphatics larger than 1 cm, fixed, irregular, or hard or rubbery require emergency investigation. Such signs raise the possibility of cancer. The signs and symptoms cited in the scenario do not indicate pneumothorax, embolus, or parotid stone.
During the health history, a client reports complaints of intermittent facial pain lasting several minutes. The nurse would suspect which of the following?
Trigeminal neuralgia
A client seeks medical attention for sharp, shooting facial pain that lasts for several minutes at a time. For which health problem should the nurse assess this client?
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by sharp, shooting, piercing facial pain that lasts from seconds to minutes. The pain occurs over the divisions of the fifth trigeminal cranial nerve. A headache associated with a fever or high blood pressure is a cluster headache. Tension headaches are caused by tightening of facial and neck muscles. Migraine headaches are provoked by hormone fluctuations.
The nurse examines a client and assesses a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which area?
Vision Explanation: A hard, thick, and tender temporal artery with absent pulsations suggests temporal arteritis, which can lead to blindness. Additional information about mental status, hearing, or neurologic status would not be needed based on this finding.
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
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. Explanation: The skull and facial bones are larger and thicker in acromegaly.
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
migraine headache. Explanation: The most common types of headaches are related to vascular (e.g., migraine), muscle contraction (tension), traction, or inflammatory causes.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first?
preauricular Explanation: 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.
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. Explanation: 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).
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 headache. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
The nurse's assessment reveals that a male client can neither turn his head against resistance nor shrug his shoulders. The nurse should document a potential deficit in the functioning of which cranial nerve?
Accessory (XI) Explanation: The eleventh cranial nerve is responsible for muscle movement that permits shrugging of the shoulders by the trapezium muscles and turning the head against resistance by the sternomastoid muscle. The abducens (VI) and trochlear (IV) nerves are involved with eye muscle movement. The hypoglossal (XII) nerve is involved with tongue muscles.
When examining a client's thyroid gland, the nurse ensures that which equipment is readily available?
Cup of water Explanation: When examining the thyroid gland, the client is asked to swallow so that each side of the gland can be felt. A cup of water would aid in swallowing. A penlight, tongue depressor, or ruler is not needed.
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?
Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
During your physical examination of the patient you note an enlarged tender tonsillar lymph node. What would you do?
Look for a source such as infection in the area that it drains Explanation: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.
Which risk factor for traumatic brain injury should a nurse include in a discussion about prevention for a group of adolescents?
Modes of transportation are the leading cause Explanation: All modes of transportation, such as motor vehicle & bicycles, are the leading cause of traumatic brain injuries for people age 5 to 64 years. Males have twice the risk of females. Firearm injuries are high in the violence category and two thirds are suicidal in intent. Fall occur most frequently in the over 65 years of age population.
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry?
Nasolabial folds Explanation: 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 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.
A client's recent weight loss and diarrhea has been attributed to hyperthyroidism. When auscultating the client's thyroid gland, what assessment finding is most consistent with this diagnosis?
A sound of turbulent blood flow in the thyroid Explanation: A soft, blowing, swishing sound auscultated over the thyroid lobes is often heard in hyperthyroidism because of an increase in blood flow through the thyroid arteries. Breath sounds and heart sounds are atypical.
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 Explanation: 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.
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.
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 Explanation: 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.
Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment? Select all that apply.
Alcohol abuse, Recreational drug use, Smokeless tobacco use and Multiple sex partners Explanation: Tobacco and alcohol use increases the risk of head and neck cancer. A more recently identified cause of head and neck cancer is exposure to human papillomavirus (HPV). People with multiple sexual partners and those who engage in oral sex are at increased risk of developing oral HPV-related cancer. For these reasons the nurse would need to perform a thorough head and neck examination.
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 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 assessment, the nurse notes an irregular rhythm. What should the nurse do next?
Assess for a pulse deficit. Explanation: If an irregular rhythm is identified, the nurse should check for a pulse deficit. The information should then be documented and the physician can be notified. There is no need to reposition the client.
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. Explanation: 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.
What does the nurse assess the face for?
Asymmetry, Edema and Involuntary movements Explanation: Note the patient's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.
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 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 is assessing a client with hyperthyroidism for the presence of a bruit. Which assessment technique should the nurse use?
Auscultation Explanation: A bruit is a soft, blowing, swishing sound auscultated over the thyroid lobes with the bell of the stethoscope that is often heard in clients with hyperthyroidism because of an increase in blood flow through the thyroid arteries. A bruit can be elicited through auscultation in a client with hyperthyroidism. A bruit cannot be elicited through inspection, palpation, or percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass.
A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?
Behind the tip of the client's mandible Explanation: The submental lymph nodes are located a few centimeters behind the tip of the mandible. The tonsillar nodes are located at the angle of the mandible, at the anterior edge of the sternomastoid muscle. The occipital nodes are at the posterior base of the skull. The postauricular nodes are behind the ears.
The nurse is assessing a client's parathyroid gland. Which is the most likely finding the nurse will encounter with hyperparathyroidism?
Decreased serum calcium level on review of labwork.
What activity is known to aggravate a tension headache?
Driving Explanation: Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.
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. Explanation: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 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 consistency, and nontender. A fixed lymph node may be seen in metastatic disease.
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 Explanation: 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.
When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. What would the nurse examine first?
Hearing acuity Explanation: A head tilted to one side may indicate unilateral vision or hearing deficiency, which should be ruled out before proceeding with the examination. The nurse would not need to evaluate the thyroid gland, mental status, or lymph nodes based on this finding.
What structure is found midline in the tracheal area just beneath the mandible?
Hyoid bone Explanation: 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 Explanation: 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.
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, bruit, and sudden weight loss, but not with any of the symptoms listed.
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place the hands at which location?
Inferior to the mandible beneath the tongue Explanation: The submandibular glands are located inferior to the mandible underneath the base of the tongue. The parotid glands are located on each side of the face, anterior and inferior to the ears. The temporal artery is located between the top of the ear and the eye. The internal jugular and carotid arteries are located bilaterally parallel and anterior to the sternomastoid muscle.
The nurse feels a small mass in the neck of a client. It is mobile in both the up-and-down and side-to-side directions. Which of the following is the nurse most likely feeling?
Lymph node Explanation: A useful way to discern lymph nodes from other masses in the neck is to check for their mobility in all directions. Many other masses are mobile in only two directions. Cancerous masses may also be fixed or immobile.
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 Explanation: 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.
The nurse places the stethoscope at the second and third left intercostal space close to the sternum to assess what heart sound?
Pulmonic Explanation: The aortic is assessed at the right second intercostal space to apex of heart. The pulmonic is assessed at the second and third left intercostal spaces close to sternum. The Left ventricular area is assessed at the second to fifth intercostal spaces, extending from the left sternal border to the left mid-clavicular line. Right ventricular area is assessed at the second to fifth intercostal spaces, centered over the sternum.
Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?
RC: Cushing's syndrome Explanation: Cushing's syndrome may present with a moon-shaped face with reddened cheeks and increased facial hair. This cluster of signs is not characteristic of CVA, thyroid disease, or acromegaly.
The nurse questions a client about any radiation therapy to the neck area based on the understanding about which of the following?
Radiation therapy has been linked to the development of thyroid cancer. Explanation: The nurse asks about a history of radiation therapy because it has been linked to the development of thyroid cancer requiring the nurse to be thorough when examining the thyroid gland. Radiation therapy is not associated with enlarged lymph nodes, reduced range of motion, or dizziness and light-headedness.
Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what?
Severe sepsis Explanation: The client is experiencing severe sepsis, the blood pressure is low, with an elevated heart rate and an elevated lactate level. There is no evidence of increased intracranial pressure, cardiac dysrhythmias or a surgical site infection.
A mother bring in her toddler to the pediatric clinic and tells the nurse practitioner that her child has "lumps in her neck that move around but do not hurt." On examination, the nurse practitioner notes lymph nodes that are less than 10 mm, nontender, and movable. How would the nurse practitioner describe findings in the medical record?
Shotty nodes Explanation: In children 1 to 5 years, nurses may palpate small (< 10 mm), nontender, movable nodes in the head and neck region. These normal findings are sometimes referred to as "shotty," because they feel like BB gun pellets or shots. The other options are distracters for the question.
Which factor, if present in a client's lifestyle and health practices assessment, would alert the nurse to the need for performing a more thorough head and neck assessment?
Smokeless tobacco use Explanation: Tobacco use increases the risk of head and neck cancer. The nurse would need to perform a thorough head and neck examination. Alcohol abuse, recreational drug use, or multiple sex partners are not risk factors associated with head and neck cancer.
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.
The client is having a thyroid crisis. What symptoms would the nurse assess for? Select all that apply.
Tachypnea, Nausea and Anxiety Explanation: 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.
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination?
red cheeks Explanation: 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.
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. Explanation: 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.
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. Explanation: Have the client remain seated upright. Then palpate the lymph nodes with your fingerpads in a slow walking, gentle, circular motion.
