HA: The Head and Neck
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?
ANSWER: atelectasis
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscle?
ANSWER: attempting to roll the structures up and down and side to side
A nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first?
ANSWER: auscultate with the bell over the lateral lobes
The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse include assessment of which affected cranial nerve in the client's head and neck assessment?
ANSWER: cranial nerve VII
The nurse is preparing to palpate the submandibular salivary glands. The nurse would place her hands at which location?
ANSWER: inferior tot he mandible beneath the tongue
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...
ANSWER: refer the client to a physician for further evaluation
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?
ANSWER: stroke
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing?
ANSWER: tension
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources?
ANSWER: the underlying bones
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....
ANSWER: tumor-related headache
