Health Assessment: Assessing Head and Neck
Primary headaches are more worrisome than secondary headaches. a) False b) True
Correct response: False
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? a) The boy requires assessment of his thyroid gland. b) There is an inflammatory response in the musculature of the boy's neck. c) There is an infection in the area that these nodes drain. d) The tissue underlying the nodes is infected.
Correct response: 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.
An adult client comes to the ED with a new onset of pain in his neck and jaw. What system requires emergency assessment? a) Nervous b) Integumentary c) Cardiovascular d) Respiratory
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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 276.
When palpating the lymph nodes of the neck, the nurse assesses for which of the following characteristics? a) Congruency, induration, size, turgor b) Delineation, integrity, shape, colour c) Configuration, discreteness, temperature, colour d) Consistency, delineation, mobility, tenderness
Correct response: Consistency, delineation, mobility, tenderness Explanation: Parameters of lymph node assessment include size, shape, delinitation, mobility, consistency, and tenderness.
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? a) C3 b) C1 c) C5 d) C7
Correct response: 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 client reports severe pain in the posterior region of the neck and difficulty turning the head to the right. What additional information should the nurse collect? a) Difficulty with swallowing b) Previous injuries to the head and neck c) Changes in sleeping habits d) Stiffness in the right shoulder
Correct response: 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.
Parents bring a school age child to the emergency department after a bicycle accident. The father tells the nurse that the child was not wearing a helmet when thrown over the handlebars, striking the child's head on the sidewalk. What would be the most important information for the nurse to include in education for this child and family? a) Use of hand signals when bike riding b) Measuring for the right size bicycle c) Use of safety equipment d) Where to find bike safety courses
Correct response: Use of safety equipment Explanation: The nurse may include all the listed information in client teaching for this client and family, but the most important information would be the use of safety equipment.
The nurse would expect to assess which symptoms in a patient complaining of migraine headaches? Select all the apply. a) continuous b) recurrent c) muscle tension d) throbbing e) photophobia
Correct response: • throbbing • photophobia • recurrent Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 291.
Where is the temporal artery palpated? a) Just left or right of the spine at the base of the skull b) Between the mandibular joint and the base of the ear c) Just left of midline at the base of the neck d) Above the cheek bone near the scalp line
Correct response: 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? a) Acute infection b) Metastatic disease c) Chronic infection d) Cushing's disease
Correct response: 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.
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? a) Muscle tension b) Bacterial thyroiditis c) Cranial damage d) Arthritic changes of the cervical spine
Correct response: 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
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? a) Ask permission before palpating the head and neck b) Palpate the client's feet before palpating the head c) Avoid asking the client to remove her clothes for the examination d) Have a nurse who is the same sex as the client perform the examination
Correct response: Ask permission before palpating the head and neck 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. 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 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? a) Assess for other signs and symptoms of Cushing's syndrome. b) Assess the woman for hypothyroidism. c) Palpate the woman's parotid gland for enlargement. d) Order tests to rule out an overactive thyroid gland.
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 279.
During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process? a) Atelectasis b) Tuberculosis c) Bronchitis d) Endocarditis
Correct response: 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 palpates an elderly client's thyroid and detects an enlargement over the right lateral lobe. What action should the nurse take first? a) Document the findings in the nurse notes b) Auscultate with the bell over the lateral lobes c) Ask the client about past history of hypothyroidism d) Immediately notify the health care provider
Correct response: 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.
Which assessment technique should a nurse use to assess for the presence of a bruit in a client with hyperthyroidism? a) Percussion b) Palpation c) Inspection d) Auscultation
Correct response: 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 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, and percussion. Inspection can only reveal swelling of the neck and palpation can indicate only the enlarged mass. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 286.
While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition? a) Bell's palsy b) Trigeminal neuralgia c) Temporomandibular joint syndrome d) Preauricular adenitis
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 293.
The nurse practitioner notes that the thyroid gland is enlarged and auscultates both lobes of the thyroid. For what is the nurse practitioner listening? a) Rush b) Gurgle c) Murmur d) Bruit
Correct response: 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. Rush and gurgle are distracters for this question. A murmur is assessed during a cardiac assessment. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 286.
The nurse is palpating a client's neck as part of a physical assessment. Which of the following blood vessels should the nurse be especially careful to avoid bilaterally compressing during the assessment? a) Internal jugular vein b) Temporal artery c) Carotid artery d) External jugular vein
Correct response: Carotid artery 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. Compression of the internal or external jugular veins would not be as significant as compressing the carotid arteries as doing so would not reduce blood supply to the brain. The temporal artery, a major artery, is located between the eye and the top of the ear, and would not be affected by palpation of the neck.
An adult client is admitted to the hospital with severe diarrhea. When assessing the client, the nurse notes a round "moon" face, a buffalo hump at the nape of the neck, and a velvety discoloration around the neck. What are these signs indicative of? a) Myxedema b) Scleroderma c) Bell's palsy d) Cushing's syndrome
Correct response: Cushing's syndrome Explanation: Cushing's syndrome, excessive production of exogenous ACTH, can result in a round "moon" facies, fat deposits at the nape of the neck, "buffalo hump," and sometimes a velvety discoloration around the neck (acanthosis nigra). The scenario does not describe a patient with myxedema, scleroderma, or Bell's palsy. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 292.
The nurse is discharging an adult client who received 18 staples for a head laceration received while mountain biking. What can the nurse focus on while doing discharge teaching? a) Teach proper posture, bending, and lifting b) Encourage proper nutrition to promote healing c) Encourage the client to take a safety course d) Encourage the use of safety equipment
Correct response: 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.
What is the most common type of hyperthyroidism? a) Moon face b) Cushing's syndrome c) Graves' disease d) Thyroid cancer
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 285.
A client presents to the health care clinic with reports of a stiff neck for the past three days. What objective information can the nurse obtain during the health history? a) Head position b) Thyroid size c) Neck tenderness d) Range of motion
Correct response: Head position Explanation: While collecting history, the nurse would be able to inspect the client to see how what position the head was being held. Range of motion would require the nurse to give the client commands while trying to obtain other information. Neck tenderness and thyroid size would require the use of palpation, not inspection. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 282.
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? a) Impending stroke b) Diabetes c) Brain tumor d) Hyperthyroidism
Correct response: 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.
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? a) Mandible b) Frontal bone c) Parietal bone d) Maxilla
Correct response: 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.
A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and nuchal rigidity. The nurse recognizes these findings as most likely to be caused by what condition? a) Parkinson's disease b) Meningeal inflammation c) Trigeminal neuralgia d) Migraine headache
Correct response: 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 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? a) Cluster b) Migraine c) Analgesic rebound d) Tension
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 290.
A client reports right-sided temporal headache accompanied by nausea and vomiting. A nurse recognizes that which condition is likely to produce these symptoms? a) Temporal arteritis b) Migraine headache c) Tension headache d) Bell's palsy
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 291.
Which instruction to the client will help facilitate examination of the temporomandibular joint by the nurse? a) Perform a chewing action b) Open the mouth c) Sit upright d) Sit without moving
Correct response: 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 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? a) Ask the doctor for an order for an MRI b) Perform a focused assessment c) Prepare the client for a spinal tap d) Perform a generalized assessment
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 273.
A client is having trouble turning her head to the side. Which of the following muscles should the nurse most suspect as being involved? a) Masseter b) Temporalis c) Trapezius d) Sternocleidomastoid
Correct response: 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 patient has an open draining wound located on the underside of the chin. Which lymph nodes should the nurse assess in this patient? a) Submental b) Preauricular c) Superficial cervical d) Tonsillar
Correct response: Submental Explanation: The submental lymph nodes are located near the region of the chin and should be assessed in the patient. Superficial cervical lymph nodes are located on the side of the neck and would not necessarily need to be assessed with the chin wound. The preauricular lymph nodes are located in front of the ear and would not necessarily need to be assessed with the chin wound. The tonsillar lymph nodes are located near the mandible and would not necessarily need to be assessed with the chin wound.
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? a) Tension pneumothorax b) Severe neck fracture c) Flail chest d) Cardiac tamponade
Correct response: 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. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 15: Assessing Head and Neck, p. 285.