N224 Chapter 13: Head, Face & Neck – Flashcards
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A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is the area:
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at the level of the C7 vertebra.
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A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall and now I have noticed that she has this spot that is soft on the top of her head. Is there something terribly wrong?" The nurse's best response would be:
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"That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."
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The nurse notices that a patient's palpebral fissures are not symmetrical. On examination, the nurse may find that there has been damage to cranial nerve:
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VII
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A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects:
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ANS: damage to the trigeminal nerve.
Facial sensations of pain or touch are mediated by cranial nerve (CN) V, which is the trigeminal nerve. Bell's palsy is associated with CN VII damage. Frostbite and scleroderma are not associated this problem.
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When examining the face, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the _____ glands.
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ANS: parotid and submandibular
Two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are not normally palpable.
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A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to cranial nerve (CN) _____ and proceeds with the examination by _____.
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ANS: XI; asking the patient to shrug her shoulders against resistance
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head.
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When examining a patient's cranial nerve (CN) function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the:
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ANS: sternomastoid and trapezius.
The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory.
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A patient's laboratory data reveal an elevated thyroxine level. The nurse would proceed with an examination of the _____ gland.
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ANS: thyroid
The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and tri-iodothyronine (T3). The other glands do not secrete thyroxine.
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A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule):
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ANS: is mobile and not hard.
Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.
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The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's:
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ANS: area proximal to the enlarged node.
When nodes are abnormal, the nurse should check the area they drain for the source of the problem. Explore the area proximal (upstream) to the location of the abnormal node.
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The nurse is aware that the four areas in the body where lymph nodes are accessible are the:
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ANS: head and neck, arms, inguinal area, and axillae.
Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.
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A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." The nurse recognizes that which statement is true regarding the relative proportions of the head and trunk of the newborn?
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ANS: Head circumference should be greater than chest circumference at birth.
During the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.
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A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give to her?
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ANS: It is probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
The facial bones and orbits appear more prominent in the aging adult, and the facial skin sags owing to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.
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A patient presents with excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that lasts about 1/2 to 2 hours, occurring once or twice each day. The nurse should suspect:
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ANS: cluster headaches.
Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1/2 to 2 hours each.
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A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from:
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ANS: migraine headaches.
Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are of a severe quality and are relieved by lying down. Migraines are associated with family history of migraines.
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A 19-year-old college student is brought to the emergency department with a severe headache he describes as "Like nothing I've ever had before." His temperature is 104° F, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem?
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ANS: Meningeal inflammation
Acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.
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During a well-baby check, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast, or "setting sun," eyes. The nurse suspects which condition?
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ANS: Hydrocephalus
Hydrocephalus occurs with obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and enlargement of the head. The face looks small compared with the enlarged cranium, and dilated scalp veins and downcast, or "setting sun," eyes are noted. Craniotabes is a softening of the skull's outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma.
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The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the:
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ANS: tragus.
The temporomandibular joint is just below the temporal artery and anterior to the tragus.
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A patient has come in for an examination and states, "I have this spot in front of my ear lobe here on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his:
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ANS: parotid gland.
Swelling with the parotid gland occurs below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.
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A male patient with a history of AIDS has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the:
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ANS: parotid gland.
The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.
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The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination?
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ANS: Tachycardia
Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.
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A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be most comfortable with the nurse examining his thyroid from:
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ANS: the front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.
Examining this patient's thyroid from the back may be unsettling for him. It would be best to examine his thyroid using the anterior approach, asking him to tip his head forward and to the right and then the left.
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A patient's thyroid is enlarged, and the nurse is preparing to auscultate the thyroid for the presence of a bruit. A bruit is a __________ of the stethoscope.
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ANS: soft, whooshing, pulsatile sound best heard with the bell
If the thyroid gland is enlarged, the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope.
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The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump about 8 hours after her baby's birth, and that it seems to be getting bigger. One possible explanation for this is:
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ANS: cephalhematoma.
A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size.
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A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborn's head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After finding this on examination, the nurse would tell her that this is:
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ANS: normal and should disappear between 3 and 4 months of age.
By 2 weeks the infant shows the tonic neck reflex when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg). The tonic neck reflex disappears between 3 and 4 months of age.
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During an examination, the nurse knows that Paget's disease would be indicated by which of these assessment findings?
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ANS: Headache, vertigo, tinnitus, and deafness
Paget's disease occurs more often in males and is characterized by bowed long bones, sudden fractures, and enlarging skull bones that press on cranial nerves causing symptoms of headache, vertigo, tinnitus, and progressive deafness.
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During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for:
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ANS: coarse facial features.
Acromegaly is excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget's disease.
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When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of:
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ANS: ear dysplasia.
With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease.
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A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has:
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ANS: had a cerebrovascular accident (stroke).
With an upper motor neuron lesion (as with CVA) the patient will have paralysis of lower facial muscles, but the upper half of the face is not affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.
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A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of:
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ANS: myxedema.
Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.
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During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be:
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ANS: firm but freely movable.
Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.
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The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is:
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ANS: pushed to the unaffected side.
The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, and pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.
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During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition?
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ANS: Dehydration
Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.
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The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of:
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ANS: allergies.
Chronic allergies often develop chronic facial characteristics. These include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose.
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While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this:
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ANS: is a normal finding for a well child of this age.
Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas, but are discrete, movable, and nontender.
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The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally:
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ANS: not palpable.
Most lymph nodes are not palpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.
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During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noticed previously. The nurse suspects that:
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ANS: this is a normal finding during pregnancy.
The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.
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During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
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ANS: Using gentle pressure, palpate with both hands to compare the two sides.
Use gentle pressure because strong pressure could push the nodes into the neck muscles. It is usually most efficient to palpate with both hands, to compare the two sides symmetrically.
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During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate?
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ANS: "Head control is usually achieved by 4 months of age."
Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.
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During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should:
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ANS: continue the examination because this is a normal finding for this age.
Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.
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During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender compared with the right temporal artery. The nurse suspects which condition?
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ANS: Temporal arteritis
The artery looks more tortuous and feels hardened and tender with temporal arteritis. These assessment findings are not consistent with the other responses.
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The nurse is assessing a 1-month-old infant at his well-baby check up. Which assessment findings are appropriate for this age? Select all that apply.
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ANS: Head circumference greater than chest circumference, Fontanels firm and slightly concave, Cervical lymph nodes not palpable
An infant's head circumference is larger than the chest circumference. At age 2, both measurements are the same. During childhood the chest circumference grows to exceed head circumference by 5 to 7 cm. Fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. Tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally not palpable in an infant.
