Ch 15 Head and Neck

The nurse is preparing to palpate a client's temporal artery. The nurse would place the hands at which location?

B) On each side between the top of the ear and the eye

A nurse is preparing to assess an adult client's carotid pulses. Which of the following actions would be contraindicated?

B) Compressing the arteries bilaterally

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?

B) Accessory (XI)

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

A) Trigeminal neuralgia

A client describes her frequent headaches as being severe and lasting for days. The client's positive response to what question would most clearly suggest to the nurse that these headaches are migraines?

D) Do you have any visual changes before the headache?

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?

C) Smokeless tobacco use

A nurse is preparing a presentation for a local community group about preventing traumatic brain injury. The nurse would discuss which measure as prevention of the leading cause?

C) Falls prevention

A nurse is palpating the head and neck of a newly referred client. Which of the following would the nurse suspect if assessment reveals that the client's skull and facial bones are larger and thicker than normal?

A) Acromegaly

When talking to a client before starting the physical exam, the nurse notes that the client consistently tilts her head to one side. Which of the following should the nurse examine first?

A) Hearing acuity

The nurse assesses a client and palpates a temporal artery that is hard, thick, and tender with absent pulsations. The nurse would gather additional information related to which aspect of health?

D) Vision

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?

D) Percussion

A nurse is palpating the position of the client's trachea. At which anatomic site would the nurse first position a finger for palpation?

B) Sternal notch

When preparing to assess a client's thyroid gland, the nurse should ensure that which piece of equipment is readily available?

D) Cup of water

Which of the following findings should the nurse document after assessing the thyroid gland of an older adult without abnormalities?

A) Nodularity

A nurse is assessing an adult client's neck. Which of the following would be most appropriate when auscultating the client's thyroid gland for bruits?

D) Have the client hold his or her breath.

A nurse is preparing to palpate a client's submental lymph nodes. At what anatomic location should the nurse position his or her hands?

D) Behind the tip of the client's mandible

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

B) Sternomastoid

A nurse has completed an assessment of a client's lymph nodes. Which of the following data would the nurse document as an abnormal finding?

C) Tender

The nurse is assessing the face of a client with a diagnosis of Parkinson's disease. Which of the following would the nurse most likely assess?

C) Masklike expression

During a health history, a client reports complaints of headaches. Which of the following would lead the nurse to suspect that the client is experiencing cluster headaches?

A) Pain radiating from eye to temporal region

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?

C) C7

A nurse is conducting a focused head and neck assessment of a client. When preparing to assess the client's thyroid gland, the nurse should be aware of which of the following principles?

B) Many clients have an additional (third) thyroid lobe.

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?

A) Referral for further assessment of thyroid function

A community health nurse is planning a health promotion campaign that will focus on cancer prevention. Which educational intervention should the nurse select in order to most influence participants' risks of head and neck cancers?

D) A smoking cessation program

25. 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?

C) RC: Cushing's syndrome

26. 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?

B) I'm going to put my fingers in front of your ears and ask you to open your mouth wide.

A nurse is performing a head and neck assessment of a client who is newly admitted to the hospital unit. When preparing to assess the client's thyroid gland, what landmarks should the nurse first identify? Select all that apply.

B, C

B) Hyoid bone

C) Cricoid cartilage

The nurse is assessing the head and neck of a 51-year-old male client. Following inspection and palpation of the client's thyroid gland, the nurse determines that the gland is enlarged. What is the next action that the nurse should perform?

C) Auscultate the client's thyroid.

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?

C) A sound of turbulent blood flow in the thyroid

A nurse has completed the assessment of an older adult client's head and neck and is now analyzing the assessment findings. Which of the following findings should the nurse attribute to age-related physiological changes?

C) Decreased strength of temporal artery pulsations