(Health Assess) Chapter 15: Assessing Head and Neck
When palpating the neck, performing which of the following techniques will help differentiate lymph nodes from a band of muscles? Applying pressure and assessing for induration Attempting to roll the structure up and down and side to side Palpating for lateral movement when the client swallows a sip of water Observing for hypertrophy when the client turns the head against resistance
Attempting to roll the structure up and down and side to side Explanation: While lymph nodes may be rolled both up and down and side to side, muscles will not move in this manner. The other cited techniques do not differentiate between lymph nodes and muscles.
What activity is known to aggravate a tension headache? Listening to music Exercise Driving Prolonged sleep
Driving Explanation: Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.
In addition to noting the physical characteristics of the thyroid gland, which of the following signs would be most important to consider in determining if the client has hypothyroidism? Increased heart rate Increased blood pressure Laboratory tests Feeling anxious
Laboratory tests Explanation: In order to determine the presence of hypothyroidism, laboratory tests to determine blood levels of the TSH, FT4 and FT1 are needed to ensure correct diagnosis of this condition. The presence of tachycardia, increased blood pressure and anxiety are signs associated with hyperthyroidism.
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? Migraine Meningitis Cervical fracture Measles
Meningitis Explanation: Neck pain associated with fever and headache may signify serious illness such as meningitis and should be carefully evaluated
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 injuries to the head and neck Difficulty with swallowing Changes in sleeping habits Stiffness in the right shoulder
Previous injuries to the head and neck Explanation: Previous head or neck injuries may cause limitations in movement and chronic pain. Change in sleeping habits is too vague to be correct. The other two options may produce pain but not necessarily limit functioning.
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 tonsillitis nasopharyngitis a goiter
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 parotid gland enlargement. acromegaly. Paget disease. Cushing syndrome.
acromegaly. Explanation: The skull and facial bones are larger and thicker in acromegaly.
As the nurse palpates the lymph nodes of the neck, hard and fixed nodes are noted in the supra-clavicular region. This finding is consistent with which condition? malignancy inflammation enlargement hypothyroidism
malignancy Explanation: Hard or fixed nodes, particularly in the supra-clavicular region of the neck, suggest a malignancy. This could even be a possible metastasis of a thoracic or abdominal malignancy. Although inflamed or enlarged nodes may be tender on palpation, the node should still be mobile. In hypothyroidism, the thyroid gland may be enlarged, but discovering hard or fixed nodes warrants further assessment for malignancy.
The nurse is planning to assess a client's lymph nodes. Which set of nodes should the nurse assess first? submental preauricular supraclavicular superficial cervical
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.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? Congruency, induration, size, turgor Delineation, integrity, shape, color Consistency, delineation, mobility, tenderness Configuration, discreteness, temperature, color
Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delineation, mobility, consistency, and tenderness.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? Open the mouth Sit upright Sit without moving Perform a chewing action
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
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 Migraine Cluster Analgesic rebound
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 Cardiac tamponade Flail chest Severe neck fracture
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.
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 cluster headaches. tumor-related headaches. migraine headaches. tension headaches.
tension headaches. Explanation: Tension headaches are dull, tight, and diffuse.
A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action? Document this as an expected assessment finding Refer the client to the primary care provider promptly Perform a focused endocrine assessment Position the client supine and reattempt palpation
Document this as an expected assessment finding Explanation: It is not unusual for the thyroid lobes to be non-palpable using the posterior approach.
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? Bell's palsy Acute pharyngitis Thyroid enlargement Parotid enlargement
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.
The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent: reduction of the blood supply to the brain. rapid rise in the client's pulse rate. premature ventricular heart sound. decreased pulse pressure.
reduction of the blood supply to the brain. Explanation: It is important to avoid bilaterally compressing the carotid arteries when assessing the neck, as bilateral compression can reduce the blood supply to the brain.
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? onset location treatment relieving factors
relieving factors Explanation: 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.
A client complains of recurring headaches that are worse when first waking in the morning and with coughing or sneezing. What would be the nurse's most appropriate action? Ask the doctor for an order for an MRI Perform a focused assessment Prepare the client for a spinal tap Perform a generalized assessment
Perform a focused assessment Explanation: Characteristics such as pain that is worse in the morning on awakening and precipitated or made worse by straining or sneezing (potentially elevated intracranial pressure) versus pain that is worse as the day progresses (more likely tension) indicate a need for a more focused assessment. Other listed options are not the most appropriate action for the nurse to take.
The nurse suspects that a client has Cushing's syndrome. What assessment finding did the nurse use to make this clinical determination? red cheeks mask-like face swelling around the eyes elongated prominent forehea
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.
A client with a cervical spine injury reports chronic pain. What would be the most appropriate initial nursing intervention for this client? Work with medical team to evaluate possible surgery. Discuss pharmacologic interventions. Educate the client regarding cervical spine pain. Assess the client regarding characteristics of the pain.
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.
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? Endocarditis Bronchitis Atelectasis Tuberculosis
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? Inspection Palpation Auscultation Percussion
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.
The nurse practitioner auscultates both lobes of a client's enlarged thyroid gland. Identification of what sound would tend to confirm a diagnosis of a toxic goiter? Rush Gurgle Murmur Bruit
Bruit Explanation: If the thyroid is enlarged, either unilaterally or bilaterally, the nurse uses the bell of the stethoscope to auscultate over each lobe for a bruit. Bruits are most often found with a toxic goiter, hyperthyroidism, or thyrotoxicosis. A murmur is assessed during a cardiac assessment.
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? C1 C3 C5 C7
C7 Explanation: 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 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? Tension Migraine Cluster Analgesic rebound
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.
A community health nurse is attending a seminar on headaches. What would this nurse learn is a red flag for headaches? Stiff neck Pain centered behind the eyes Pain that is temporary Pain without new symptomatology
Stiff neck Explanation: Limitation of neck mobility may be from muscle tension/strain or cervical vertebral joint dysfunction.
x 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 Migraine Cluster Analgesic rebound
Tension Explanation: This is a description of a typical tension headache.
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 migraine headache. cluster headache. tension headache. tumor-related headache.
tumor-related headache. Explanation: Tumor-related headaches have no prodromal stage; may be aggravated by coughing, sneezing, or sudden movements of the head.
While performing an examination of the head and neck, a nurse notices left-sided facial drooping. The nurse recognizes this as what condition? Trigeminal neuralgia Preauricular adenitis Temporomandibular joint syndrome Bell's palsy
Bell's palsy Explanation: One-sided facial drooping is present in Bell's palsy due to inflammation of the facial nerve. Trigeminal neuralgia causes shooting, piercing facial pains that occur over the divisions of the fifth cranial nerve. Preauricular adenitis is characterized by tenderness and swelling of the lymph nodes in front of the ears. Temporomandibular joint syndrome causes pain or crepitation with jaw movement.
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? Cardiovascular Integumentary Respiratory Nervous
Cardiovascular Explanation: Acute situations that need emergency assessment and intervention include head or neck injuries, neck pain (may be cardiac), enlarged hard nodes (which may indicate cancer), and thyrotoxicosis. The other options are, therefore, incorrect.
A nurse performs palpation of a client's lymph nodes. Which finding should be reported to the health care provider? Mobile from side to side Soft in consistency Fixed to underlying tissue Round and 8 mm in size
Fixed to underlying tissue Explanation: Normally lymph nodes are round and soft, less than 1 cm in size, mobile from side to side, soft in consistency, and nontender. A fixed lymph node may be seen in metastatic disease.
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? Meningeal inflammation Stress Injury to the sternomastoid Arthritis
Arthritis Explanation: Older clients who have arthritis or osteoporosis may experience neck pain and a decreased range of motion. Sudden head and neck pain seen with elevated temperature and neck stiffness may be a sign of meningeal inflammation. Stress and tension may increase neck pain. Neck pain may accompany muscular problems or cervical spinal cord problems.
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? Nurses need to follow lymph patterns to track the course of a disease. The drainage pattern can help the nurse understand why the disease is spreading. Enlargement of a node may be a sign of pathology that is distant from that node. The drainage pattern may help pinpoint a fluid or electrolyte imbalance.
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.
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? Diabetes Brain tumor Impending stroke Hyperthyroidism
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.
What is the most common type of hyperthyroidism? Graves' disease Cushing's syndrome Moon face Thyroid cancer
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 at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect? Effects of age-related changes Brain tumor Hyperthyroidism Hypothyroidism
Hypothyroidism Explanation: Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.
What risk factors should the nurse include in a discussion on the occurrence of neck cancer? (Select all that apply.) Female gender Male gender Coffee drinker Tobacco use Age older than 50 years
Male gender Tobacco use Age older than 50 years Explanation: Risk factors for neck cancers include male gender, age older than 50 years, tobacco use, and alcohol consumption. For clients with such risk factors, nurses should especially emphasize teaching related to smoking prevention or cessation. Risk factors do not include female gender or being a coffee drinker.
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? Bell's palsy Tension headache Temporal arteritis Migraine headache
Migraine headache Explanation: 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 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? Submandibular Tonsillar Occipital Posterior cervical
Posterior cervical Explanation: The group of nodes posterior to the sternocleidomastoid muscle is the posterior cervical chain. These are common in mononucleosis.
A young adult client has just had X-rays and computed tomography scanning of the head and neck following a mountain bicycling accident. All results are negative. What should the nurse assess for next? Range of motion of the neck Headache Shortness of breath Range of motion of the arms and shoulders
Range of motion of the neck Explanation: Musculoskeletal injury or disease can be confirmed with an X-ray, CT, or MRI. If test results are negative, the nurse should assess for complete range of motion of the neck, looking for any muscle tension, loss of mobility, or pain. According to the scenario, the nurse would not assess for headache, shortness of breath, or ROM of the arms and shoulders next.
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 Trapezius Masseter Temporalis
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).
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 Multiple sex partners
Alcohol abuse Recreational drug use Smokeless tobacco use 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 nurse palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? Immediately notify the health care provider Document the findings in the nurse notes Auscultate with the bell over the lateral lobes Ask the client about past history of hypothyroidism
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.
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 Encourage proper nutrition to promote healing Encourage the client to take a safety course Teach proper posture, bending, and lifting
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.
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? A tumor Hypothyroidism Graves' disease Nephrotic syndrom
Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
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? Range of motion Head position Neck tenderness Thyroid size
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 assesses a client's submental lymph nodes. In which area of the client's head should the nurse palpate these lymph nodes? Superficial to the sternomastoid In front of the ear In the midline, a few centimeters behind the tip of the mandible At the angle of the mandible
In the midline, a few centimeters behind the tip of the mandible Explanation: The submental lymph nodes are located near the midline, a few centimeters behind the tip of the mandible. Superficial cervical lymph nodes are located superficial to the sternomastoid. The preauricular lymph nodes are located in front of the ear. The tonsillar lymph nodes are located near the mandible.
During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? Assess for meningitis Look for involvement of other regions of the body Look for a source such as infection in the area that it drains Assess for dietary changes
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.
When preparing to provide education regarding the prevention of head injuries from motor vehicle accidents, the nurse should be sure to include which point? Mobile phones should only be used if there is a hands-free option available. A car seat should only be installed in the front if there are passenger airbags available. Refrain from taking any medication prior to operating a motor vehicle. Helmets can obscure vision when riding all-terrain vehicles and should be avoided.
Mobile phones should only be used if there is a hands-free option available. Explanation: Only hands-free mobile phones can be used when driving, and text messaging is prohibited due to the risk for distraction. Small children should only sit in the back of the motor vehicle, especially if there is a passenger side airbag. Only medications with side effects such as fainting or dizziness should be avoided. Helmets should always be worn when riding motorcycles, all-terrain vehicles, motorized scooters, bicycles, horses, and snowmobiles.
A nurse is performing a head and neck assessment on a client. Which area should the nurse inspect for facial symmetry? Nasolabial folds Temporomandibular joint Preauricular nodes Earlobes
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.
While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing a/an enlarged thyroid. lymph node abscess. neurologic disorder. parotid gland enlargement.
parotid gland enlargement. Explanation: Asymmetry in front of the earlobes occurs with parotid gland enlargement from an abscess or tumor.
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. Administer intravenous pain medication. Palpate the carotid pulses bilaterally at the same time. Prepare the client for a temporal artery biopsy.
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.
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 ask the client to flex his neck to the left side. observe whether the client has difficulty swallowing water. refer the client to a physician for further evaluation. palpate the cricoid cartilage for smoothness.
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.
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 A woman who complains of recurrent headaches near the end of her workday spent at a computer station A man who has sought care for treatment of his episodic headaches that occur several times each day A man whose headaches are accompanied by severe light sensitivity but an absence of nausea
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.
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 explain to the client why the assessment is necessary. ask the client if touching the head is permissible. determine whether the client desires a family member present. examine the lymph nodes of the neck before examining the head.
ask the client if touching the head is permissible. Explanation: 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.
The nurse is preparing to assess the neck of an adult client. To inspect movement of the client's thyroid gland, the nurse should ask the client to inhale deeply. swallow a small sip of water. cough deeply. flex the neck to each side.
swallow a small sip of water. Explanation: Ask the client to swallow a small sip of water. Observe the movement of the thyroid cartilage, thyroid gland.
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? A tumor Hypothyroidism Graves' disease Nephrotic syndrome
Graves' disease Explanation: Graves' disease is associated with a diffusely enlarged thyroid. This finding is not normally consistent with neoplasm, hypothyroidism, or nephritic syndrome.
A client complains of a headache over both temporal areas. What type of headache should the nurse suspect the client is experiencing? cluster tension migraine hypertensive
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.
In reviewing a client's health history, the nurse notes that the client has had a history of TMJ pain. The nurse recognizes that which of the following bones is involved in this dysfunction? Frontal bone Maxilla Parietal bone Mandible
Mandible Explanation: The mandible (jaw bone) provides the structural support for the floor of the mouth and, with the temporal bone, forms the temporomandibular joint (TMJ). The other bones listed are part of the skull but are not associated with the TMJ.
When examining the head, the nurse remembers that the anatomic regions of the cranium take their names from which of the following sources? Noted anatomists The underlying bones Their anatomical positions The underlying vascular network
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.
Where is the temporal artery palpated? Above the cheek bone near the scalp line Just left of midline at the base of the neck Between the mandibular joint and the base of the ear Just left or right of the spine at the base of the skull
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? Metastatic disease Chronic infection Acute infection Cushing's disease
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.
The nurse suspects an enlarged thyroid in a client during the physical examination of the head and neck. What should the nurse do first? Displace the trachea to the right. Listen over the thyroid with a stethoscope. Ask the client to sip and swallow water. Ask the client to lie down for further assessment
Ask the client to sip and swallow water. Explanation: In order to determine if the thyroid gland is enlarged, the first step in the physical assessment is to ask the client to sip some water, extend the neck and swallow. By doing so, the nurse can watch for upward movement of the thyroid gland and determine if the gland is enlarged. Once it confirmed that the thyroid gland is enlarged, it would be the next step for the nurse to listen over the lateral lobes with a stethoscope to detect a bruit. Displacing the trachea would not be part of the assessment; however, the nurse would need to inspect the trachea for deviations that may push it to one side. Assessment of the thyroid gland can be done while the client is sitting up from either an anterior or posterior approach. The assessment cannot be effectively done with the client lying down.
A 57-year-old client reports, "I am having the worst headache I have ever experienced." Which action should the nurse perform next? Assess the client's blood pressure. Provide medication for pain relief. Inquire about family history of headaches. Review the client's medical record.
Assess the client's blood pressure. Explanation: Onset of headache after the age of 50 paired with the statement the client has made here is considered a "red flag." The nurse should suspect this is a secondary headache or arising from another condition. Markedly elevated blood pressure could be indicative of imminent danger to the client's life. Assessment of the blood pressure should be the nurse's first action.
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? Educating them about not drinking and driving Teaching them how to turn these clients every 2 hours Fulfilling the court requirements Keeping the shelves restocked
Educating them about not drinking and driving Explanation: 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 clients, fulfilling court requirements, or keeping the shelves restocked.
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? A mnemonic assessment tool Headache Impact Test Auscultation Family health history questionnaire
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.
What structure is found midline in the tracheal area just beneath the mandible? Cricoid cartilage Hyoid bone Thyroid cartilage Adam's apple
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? Cricoid cartilage, hyoid bone, tracheal rings, thyroid isthmus Thyroid cartilage, thyroid isthmus, cricoid cartilage, hyoid bone Hyoid bone, thyroid cartilage, cricoid cartilage, isthmus of the thyroid Hyoid bone, tracheal rings, cricoid cartilage, lobes of the thyroid gland
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.
An older adult presents at the clinic with reports of a painful neck. On palpation, the nurse notes a hard, nonmovable mass, approximately 20 mm, that is painful to touch. The area seems to have several nodes matted together. How would the nurse chart this last finding? Nodes feel matted together on palpation Nodes are delimited on palpation Nodes appear grown together on palpation Nodes are demarcated on palpation
Nodes are delimited on palpation Explanation: Usually, no lymph nodes are palpable in the adult. If a node is palpable, it is important to describe the following characteristics: location-which lymphatic chain and where along that chain is the node; size-in mm or cm; consistency-how hard or soft is the node; mobility-it should be freely movable; delimitation-there should not be any matting together of lymph nodes. The other options do not demonstrate accurate documentation.
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? The boy requires assessment of his thyroid gland. There is an inflammatory response in the musculature of the boy's neck. The tissue underlying the nodes is infected. There is an infection in the area that these nodes drain.
There is an infection in the area that these nodes drain. Explanation: Whenever a lymph node is enlarged or tender, the nurse should assess for infection in the area that the particular nodes drain. Thyroid or muscular involvement is less likely, and infection does not likely underlie the nodes directly.
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 This could be a sign of pneumothorax This could be a sign of an embolus This could be a sign of a parotid stone
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.
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 thyroid cyst Hashimoto thyroiditis benign tumor
hyperthyroidism Explanation: 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.
