Head/Neck Assessment
Moon shaped face, with reddened cheeks and increased facial hair are symptoms of what condition?
Cushing Syndrome
What is the character of a sinus headache?
Deep, constant throbbing pain; pressure-like pain in one specific area of face or head (i.e. behind eyes); face tender to the touch
Teenagers doing community service following arrest for driving under the influence are working at the rehabilitation hospital with clients who have paraplegia. These clients have been paralyzed by drunk drivers. How would the nurses who care for these clients best use the time spent with these teenagers?
Education for high-risk groups about not driving while under the influence or sleepy is critical. The nurses working with these clients would not spend time with the teenagers teaching them how to turn the patients, fulfilling court requirements, or keeping the shelves restocked.
Exophthalmus is commonly seen in which condition?
Hyperthyroidism
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 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.
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 Migraine headaches are usually located around the eyes, temples, cheeks, and forehead. They are often accompanied by nausea and vomiting. Bell's palsy is a one sided facial paralysis caused by inflammation of the facial nerve. A tension headache usually presents with stress, anxiety, or tension and is located in the frontal, temporal, or occipital region. Temporal arteritis produces pain around the temple but no nausea or vomiting.
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
Tension headaches are dull, tight, and diffuse.
Why must we avoid bilateral compression of the carotid arteries?
because we don't want to reduce blood flow to the brain
Severity of sinus headache
may be moderately severe; not debilitating
Location of sinus headache
may occur in one area of face or along eyebrow ridge or below the cheek bone
Does bell's Palsy cause one or two sided face paralysis?
one sided facial paralysis
How many types of headaches are there?
5
A client is experiencing pain around the eye that radiates to the face and temporal area. Which image diagrams this client's pain?
A cluster headache is localized in the eye and orbit and radiates to the facial and temporal regions. A sinus headache occurs along the eyebrows and below the cheek bone. A tension headache is usually located in the frontal, temporal, or occipital region. A migraine headache is usually located around eyes, temples, cheeks, or forehead and may affect only one side of the face.
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 neck and head 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. There is no need to avoid asking the client to remove clothes for the examination; removing clothing is not a particular concern related to this client's culture nor is it necessary for examination of the head and neck. Clients of certain conservative religious backgrounds may object to being assessed by a nurse of the opposite sex, but there is not enough information in this scenario to warrant such a concern.
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 replacement for the rest of my life 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.
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 Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated.
Signs and symptoms of a stroke?
Remember act FAST Face: ask to smile, does one side of face droop? Arms: ask to raise both arms, does one arm drift downward? Speech: Ask the person to repeat a simple phrase, is their speech slurred or strange? Time: If you observe any of these signs, call 911 immediately act Fast!
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.
Duration of sinus headache
last until associated condition is improved
what is the onset/precipitating factors of a sinus headache?
occurs with or after a cold or acute sinusitis or acute fibrile illness w/ purulent discharge from nose
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 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).
What is the most common type of hyperthyroid disease?
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 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?
Hyperthyroidism 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 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?
Parkinsons disease 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.
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.
What are the 5 types of headaches?
Sinus headache Cluster headache Tension headache Migraine headache Tumor-related headache
The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. Which condition is most likely?
hyperthyroidism The low, soft, rushing sound is a systolic or continuous bruit commonly heard in hyperthyroidism. A bruit is not commonly auscultated in Hashimoto thyroiditis. Identifying characteristics of this condition include enlarged, firm, and rubbery thyroid glands with no bruit. Thyroid cysts and benign malignancies would not have a low, soft, rushing sound that can be auscultated.
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 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.
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 The cervical vertebrae (C1 through C7) are located in the posterior neck and support the cranium. The vertebra prominens is C7, which can easily be palpated when the neck is flexed. Using C7 as a landmark will help you to locate other vertebrae.
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 information about the severity. This subjective information is categorized as a characteristic symptom. Information about anything else that the client may be experiencing during the headache (for example, nausea or blurred vision) should be documented in associated manifestations. Relieving factors provides information about anything that the client has attempted to relieve the symptoms. The location provides subjective information about where the headache is localized and pain radiates.
A male college student presents to the student health clinic with reports of night-time headaches for the past 2 weeks. He denies nausea or photosensitivity but states that he has noticed his eyes are tearing and his nose runs a lot. He is stressed because of final exams and confesses to drinking more alcohol than normal. The nurse recognizes these findings as indicative of what type of headache?
Cluster Cluster headaches occur more often in young males, have a sudden onset, and may be precipitated by ingestion of alcohol. The headaches typically occur in the evening and are localized to the eyes, with radiation into the facial and temporal areas. The person may report tearing of the eye or runny nose. Migraine headaches are accompanied by nausea, vomiting, and sensitivity to light and sound. Tension headaches occur more frequently in females and are usually a result of stress, anxiety, or depression.
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 (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).
