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306 PHYSICAL EXAMINATION
A. Anterior approach
B. Posterior approach
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UNIT 2
FIGURE 9.19 Solitary thyroid nodule
COUR TESY OF DR A NDREW B. SI LVA, PEDIATR ICOTOL ARYNGO LOGY
Examination of regional lymphatics: the thyroid gland
Inspection
E
1. Secure tangential lighting, and shine it at an oblique angle on the consumer’s
anterior neck.
2. Face the consumer.
3. Ask the consumer to look straight ahead with the head slightly extended.
4. Have the consumer drink a sip of water and swallow twice.
5. As the consumer swallows, observe the front of the neck in the area of the
thyroid and the isthmus for masses and symmetrical movement.
N
Thyroid tissue moves up with swallowing, but often the movement is so small
that it is not visible on inspection. In males, the thyroid cartilage, or Adam’s
apple, is more prominent than in females.
A mass or enlargement of the thyroid that moves upwards with swallowing is
A
not normal.
Many
P
Palpation
Palpation of the thyroid gland may be done using both anterior and posterior
approaches (
goitres (enlarged thyroid glands) or thyroid nodules are visible and may
indicate a variety of thyroid diseases (
Figure 9.19).
Figure 9.20).
FIGURE 9.20 Examination of the
thyroid gland
Anterior approach
1. Stand in front of the consumer.
P
2. Ask the consumer to flex the head slightly forwards.
3. Place the right thumb on the thyroid cartilage and displace the cartilage to
the consumer’s right.
4. Grasp the elevated and displaced right lobe of the thyroid gland with the
thumb and index and middle fingers of the left hand.
5. Palpate the surface of the gland for consistency, nodularity and tenderness.
6. Have the consumer swallow, and then palpate the surface again.
7. Repeat the procedure on the opposite side.
N
No enlargement, masses or tenderness should be noted on palpation.
Palpation reveals the gland to be smooth, soft and slightly enlarged but less than
A
twice the size of a normal thyroid gland.
This is referred to as physiological hyperplasia and can be seen
P
premenstrually, during pregnancy, or from puberty to young adulthood
in females. Symmetrical enlargement may also be noted in consumers who
live in areas of iodine deficiency. These are referred to as nontoxic diffuse
goitres or endemic goitres.
Palpation reveals the gland to be two to three times larger than normal size.
A
This is diffuse toxic hyperplasia of the thyroid, or Graves’ disease, an
P
autoimmune disorder that is the most common type of hyperthyroidism.
Table 9.2 distinguishes between the signs and symptoms of thyroid disorders.
In addition,
Because the parathyroid glands can be affected with thyroid manipulation,
it is imperative that the examiner has the clinical knowledge of pathology
of the parathyroid glands.
Table 9.3 identifies signs and symptoms of parathyroid disease.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
HEAD, NECK AND REGIONAL LYMPH NODES 307
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Asymmetrical enlargement of the thyroid and the presence of two or more
A
nodules are found.
These are thyroid adenomas (benign epithelial tumours) that usually occur
P
after the age of 30. A nontoxic, diffuse goitre may become nodular as the
consumer ages.
Palpation reveals a solitary nodule in the thyroid tissue.
A
A solitary nodule is suggestive of carcinoma (Figure 9.19).
Lateral deviation of the trachea is noted on palpation, but you are unable to
A
identify a specific goitre.
This may be a retrosternal goitre. This type of goitre sometimes occurs in
P
a consumer with a short neck, or it may be a goitre with many
adenomatous nodules.
TABLE 9.2 Signs and symptoms of thyroid disease
Hypothyroidism and hyperthyroidism are diseases that can occur from birth until later years of life. They can
be congenital or acquired. The primary laboratory tests that are used to screen for these conditions are the
thyroid stimulating hormone (T
SH), T
and T4.
3
SYSTEM HYPOTHYROIDISM HYPERTHYROIDISM
General Tired, weak Fatigue, weak
CHAPTER 9
Skin Dry, cold, coarse Sweaty, warm
Hair
Head and neck Hoarseness, puffy face
Alopecia Thin hair
Lid lag, exophthalmos, goitre
Ears and mouth Impaired hearing, macroglossia None
Respiratory Dyspnoea Tachypnoea
Cardiovascular Bradycardia, cool extremities, peripheral
Tachycardia, palpitations
oedema
Gastrointestinal Constipation Diarrhoea
Musculoskeletal Carpal tunnel syndrome Muscle weakness
Neurological Difculty concentrating, decreased
memory, paraesthesia, decreased deep
Hyperactivity, irritability, tremor,
insomnia
tendon reexes
Reproductive Amenorrhoea Oligomenorrhoea, gynaecomastia in men,
decreased libido, decreased fertility
Endocrine Cold intolerance Heat intolerance
Weight Weight gain with decreased appetite Weight loss with increased appetite
Tenderness of the thyroid is found on palpation.
A
Tenderness of an enlarged, firm thyroid suggests thyroiditis.
P
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
308 PHYSICAL EXAMINATION
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UNIT 2
TABLE 9.3 Signs and symptoms of parathyroid disease
Hypoparathyroidism and hyperparathyroidism are diseases that can occur congenitally or be acquired.
Both are primarily conditions of calcium imbalance. In hypoparathyroidism, the consumer is in a state of
hypocalcaemia; in hyperparathyroidism, the consumer is hypercalcaemic. The body has four parathyroid
glands, located posterior to the thyroid. Occasionally, they are accidentally removed when a consumer
undergoes thyroid surgery. The parathyroid glands are not accessible to direct physical examination, but
parathyroid conditions can be detected by astute history taking and physical assessment data synthesis.
HYPOPARATHYROIDISM HYPERPARATHYROIDISM
Muscle spasms Recurrent nephrolithiasis
Facial grimacing
Laryngeal spasm Mental status changes
Seizures Proximal muscle weakness
Mental status changes Fatigue
Tetany
Chvostek sign (see Chapter 16) Osteitis brosa cystica
Trousseau sign (see
Chapter 16)
Peptic/duodenal ulcers
Muscle atrophy
Posterior approach
E
1. Have the consumer sit comfortably. Stand behind the consumer.
2. Have the consumer lower the chin slightly in order to relax the neck muscles.
3. Place the thumbs on the back of the consumer’s neck and bring the other
fingers around the neck anteriorly with their tips resting on the lower
portion of the neck over the trachea.
4. Move the finger pads over the tracheal rings.
5. Instruct the consumer to swallow. Palpate the isthmus for nodules
or enlargement.
6. Have the consumer incline the head slightly forwards.
7. Press the fingers of the left hand against the left side of the thyroid cartilage
to stabilise it while placing the fingers of the right hand gently against the
right side.
8. Instruct the consumer to swallow sips of water.
9. Note consistency, nodularity and tenderness as the gland moves upwards.
Refer to Anterior approach.
N A P
Auscultation
If the thyroid is enlarged, auscultation should be performed.
E
1. Stand in front of the consumer.
2. Place the bell of the stethoscope over the right thyroid lobe.
3. Auscultate for bruits.
4. Repeat on the left thyroid lobe.
Auscultation should not reveal bruits.
N
Auscultation reveals the presence of a bruit over an enlarged thyroid gland.
A
Bruits occur with increased turbulence in blood vessels and are due to the
P
increased vascularisation of a thyroid gland that is enlarged due to diffuse
toxic goitre.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
Advanced Assessment
HEAD, NECK AND REGIONAL LYMPH NODES 309
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REFLECTION IN PRACTICE
Pregnant woman with neck asymmetry
It is widely recognised that thyroid disease can affect the pregnant woman and the
development of the fetus. In the presence of iodine deciency, enhanced thyroid stimulation
during pregnancy can lead to goitre formation in the mother and fetus.
You are assessing a pregnant 22-year-old woman who has recently moved to New
Zealand from Samoa. She has received limited medical care her entire life and no prenatal
care for this pregnancy. She presents with a unilateral bulge on the left side of her neck.
How would you proceed with gaining a health history and physical examination? What
might be the aetiology of this neck asymmetry?
For further information refer to your organisation’s clinical guidelines or the Australian
Government, Pregnancy Care Guidelines: https://www.health.gov.au/resources/pregnancycare-guidelines
HEALTH EDUCATION
Risk factors for thyroid cancer
When assessing a consumer’s neck for possible thyroid abnormalities, identify risk factors
for thyroid cancer. Keep in mind the following considerations.
> Age (females 40–50 years; male 60–70 years)
> Female sex
> Diet low in iodine
> History of head or neck radiation, especially in childhood
> Exposure to nuclear weapons (Hiroshima)
> Genetics (e.g. familial medullary thyroid carcinoma)
If the consumer is identied as having any of these risks, discuss the need for further
investigation and the need for a health referral.
CHAPTER 9
Examination of regional lymphatics: the lymph nodes
Inspection
E
1. Stand in front of the consumer.
2. Expose the area of the head and neck to be assessed.
3. Inspect the nodal areas of the head and neck for any enlargement
or inflammation.
N
Lymph nodes should not be visible or inflamed.
Enlargement and inflammation is present in specific nodes.
A
Lymph nodes can be enlarged and inflamed when there is a localised or
P
generalised infection in the body. This attempt to prevent the spread of infection
occurs as a part of the body’s immune response to infection.
Palpation
E
1. Have the consumer sit comfortably.
2. Face the consumer and conduct the assessment of both sides of the neck
simultaneously.
3. Move the pads and tips of the middle three fingers in small circles of
palpation using gentle pressure.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
310 PHYSICAL EXAMINATION
A. Preauricular
B. Postauricular
C. Occipital
D. Submental
E. Submandibular
F. Tonsillar
G. Anterior cervical chain
H. Posterior cervical chain
I. Supraclavicular
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UNIT 2
E
4. Follow a systematic, routine sequence beginning with the preauricular,
postauricular, occipital, submental, submandibular and tonsillar nodes. Move
down to the neck and evaluate the anterior cervical chain, the posterior
cervical chain, and the supraclavicular nodes (see
Figure 9.21).
5. Note size, shape, delimitation (discrete or matted together), mobility,
consistency and tenderness.
N
Lymph nodes should not be palpable in the healthy adult consumer; however,
small, discrete, movable nodes are sometimes present but are of no significance.
Palpable lymph nodes are abnormal.
A
Palpable lymph nodes are frequently seen in acute bacterial infections such as
P
streptococcal pharyngitis. The anterior cervical nodes are usually affected and
may be warm, firm, tender and mobile. A lymph node that is larger than 1cm in
size should be evaluated in greater depth.
An enlarged postauricular node is sometimes found in consumers with
P
ear infections.
Enlarged, hard, tender nodes are seen in lymphadenitis (inflammation of the
P
lymph nodes). The affected node is the site of the inflammation.
Enlarged nodes, particularly of the anterior and posterior cervical chains, may be
P
found in infectious mononucleosis. These nodes are usually tender.
An enlarged node in the left supraclavicular area (Virchow’s node) may point to
P
malignancy in the abdominal or thoracic regions.
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
FIGURE 9.21 Palpation of lymph nodes
HEAD, NECK AND REGIONAL LYMPH NODES 311
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Nontender, firm or hard nodes that are nonmobile may indicate a malignancy in
P
the head and neck area, or metastasis from the region that the lymph
node drains.
Consumers with malignant lymphomas may also present with nodes that are
P
firm, hard or rubbery; nontender; and fixed. In Hodgkin’s disease, the cervical
nodes are frequently the first to be palpable.
Palpable lymph nodes can result from a variety of other pathological processes,
P
including blood dyscrasias, AIDS, tuberculosis, surgical procedures that
traumatise the nodes, blood transfusions or chronic illness.
EVALUATION OF HEALTH ASSESSMENT AND PHYSICAL
EXAMINATION FINDINGS
In the evaluation phase of a health assessment, the focus is on ensuring the data
gathered is complete, accurate and documented appropriately (see case study as
an example of the focused assessment; see Chapter 22 for a comprehensive health
assessment). In evaluating the data you should:
> draw on your critical thinking and problem-solving skills to make sound
clinical decisions
> act on abnormal data (include communicating findings to other
health professionals)
> ensure documentation reflects the outcomes of the clinical decisions/actions
taken (refer to Chapter 3, which discusses in detail why documentation is so
important and how this may be undertaken in different health settings).
The case study that follows steps you through this process.
By using the following case study, you will be able to follow this process.
CHAPTER 9
THE CONSUMER WITH HYPERTHYROIDISM, GRAVES’ DISEASE
This case study illustrates the application and objective
documentation of the head, neck and regional lymph
node assessment.
HEALTH HISTORY
CONSUMER PROFILE 54-year-old male
CHIEF COMPLAINT ‘I just haven’t felt right for the past couple of months.’
HISTORY OF THE PRESENT
ILLNESS
Consumer reports that he was doing well until 9 months ago, when he saw his general practitioner for
his 6-month check-up for hypertension and hyperlipidaemia. At that time, he was noted to have tonsillar
enlargement and was referred to an ENT specialist. Subsequently, he was diagnosed with squamous cell
carcinoma of the tonsils. His tonsils were removed and he received a 6-week course of external beam radiation
to the tonsillar region. He had an uneventful postoperative period and resumed work. About 2 months ago,
Samuel developed signs of myalgias and complained of general weakness. He denies experiencing dysphagia,
hoarseness, any fever, shortness of breath, palpitations, diarrhoea, tremor, heat intolerance. He has lost 4kg
since his surgery. Samuel is concerned about the effects of his current health status because he has no more
sick leave this year due to his earlier surgery and radiation therapy treatments.
Samuel Norris is a 54-year-old man who has not been feeling well
the past few months.
CASE STUDY
>>
E
ExaminationNNormal ndingsAAbnormal ndingsPPathophysiology
312 PHYSICAL EXAMINATION
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>>
HEALTH HISTORY
PAST HEALTH HISTORY MEDICAL HISTORY Hypertension for 10 years, controlled with medications. Takes BP at home
UNIT 2
SURGICAL HISTORY Appendectomy 1975
ALLERGIES Allergic to penicillin, breaks out in hives
MEDICATIONS Metoprolol 50mg oral daily
COMMUNICABLE DISEASES Chickenpox, age 3
INJURIES AND ACCIDENTS 1993 playing AFL and tore ACL, repaired early 1996
SPECIAL NEEDS Nil reported
BLOOD TRANSFUSIONS Nil reported
CHILDHOOD ILLNESSES Mumps, age 4
IMMUNISATIONS Had latest inuenza vaccination and his tetanus is up to date
every two days and records the results
ACL repair 1996
Tonsillectomy, 3.5 months ago
Ezetimibe 10mg oral daily
Aspirin 100mg oral daily
FAMILY HEALTH HISTORY Denies family history of thyroid disease
SOCIAL HISTORY ALCOHOL USE 2 beers each night at home and after work on Friday. Goes out for a few
beers with work friends sometimes
TOBACCO USE 8–10 cigarettes a day for the past 6 months; prior to this he smoked 40
cigarettes/day for 30 years and an occasional cigar on the weekend
DRUG USE Marijuana in high school; continued use on irregular basis until age 30
DOMESTIC AND INTIMATE
PARTNER VIOLENCE
SEXUAL PRACTICE Good relationship with wife of 30 years
TRAVEL HISTORY Travels interstate to follow touring car championships
WORK ENVIRONMENT Manager of a busy Australia Post service vehicle maintenance unit. Has
HOME ENVIRONMENT Lives in low-set brick home with wife and 23-year-old son. No major
HOBBIES AND LEISURE
ACTIVITIES
STRESS ‘My health and bills, bills, bills and work, work, work.’
EDUCATION ‘I nished high school, and that was enough for me.’
States no issues
a few staff and been there for 20 years. Work space is crowded; he has a
dirty ofce from exhaust fumes from cars all day
environmental risks noted
Poker once a month, watching touring car and rally car races in New
Zealand on TV, attending Australian touring car races when able
ECONOMIC STATUS ‘We aren’t starving.’
MILITARY SERVICE None
RELIGION Uniting Church
CULTURAL BACKGROUND Caucasian
ROLES AND RELATIONSHIPS Samuel and his wife get along ‘OK’. ‘I get on well with my son. He lives at
home and we love watching the car racing and car rallies together.’ ‘Bit of
stress with the big boss at work, but nothing I can’t handle.’
>>
HEAD, NECK AND REGIONAL LYMPH NODES 313
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>>
HEALTH HISTORY
CHARACTERISTIC PATTERNS OF
DAILY LIVING
HEALTH MAINTENANCE
ACTIVITIES
SLEEP 7½ hours per night; usually feels rested
DIET ‘I grab something when I can at work. It should be low-fat, low-cholesterol
EXERCISE ‘Oh not much, but I want to do more.’
STRESS MANAGEMENT ‘A good beer helps me relax.’
USE OF SAFETY DEVICES ‘At work we are very regulated. That’s a big part of my role, to ensure the
HEALTH CHECK-UPS ‘Usually 6 monthly for my BP and general health; I have had more visits
PHYSICAL EXAMINATION
EXAMINATION OF THE
HEAD
EXAMINATION OF THE
SCALP
INSPECTION SHAPE OF THE HEAD Normocephalic and symmetrical
PALPATION Skull smooth, no tenderness, masses or depressions; temporal artery
INSPECTION AND PALPATION Scalp smooth and intact, no lesions or masses
Wakes at 5:30 a.m., showers, has coffee and cereal; arrives at work at
7 a.m.; smokes a cigarette; black coffee throughout the day; fast-food
for lunch, but lately has been trying to cut down on fried food; leaves
work at 4 p.m., comes home and has 2 beers; eats dinner with wife and
son, if he is at home, and then watches TV; in bed by 10 p.m.
with lots of sh; I am trying to be better about my diet.’
safety of vehicles and drivers.’
lately with the tonsil cancer.’
1+/4+ with mild tenderness, mildly stiff vessel
CHAPTER 9
EXAMINATION OF THE
FACE
EXAMINATION OF THE
MANDIBLE
EXAMINATION OF THE
NECK
EXAMINATION OF THE
REGIONAL LYMPHATICS:
THE THYROID GLAND
EXAMINATION OF THE
REGIONAL LYMPHATICS:
THE LYMPH NODES
DIAGNOSTIC DATA
TSH
INSPECTION
PALPATION AND AUSCULTATION Temporomandibular joint articulates smoothly, no clicking or crepitus
INSPECTION Muscles symmetrical, full range of movement
PALPATION No palpable masses or spasms reported
INSPECTION Moves with swallowing
PALPATION
AUSCULTATION Bruits noted
INSPECTION Enlargement noted
PALPATION Adenopathy (enlargement noted)
Complete metabolic panel – Within normal ranges
CONSUMER’S VALUES NORMAL RANGE
<0.30mIU/L
SYMMETRY Symmetrical, no involuntary movements
or swelling
SHAPE AND FEATURES Round, no oedema or involuntary
movements; no exophthalmos
ANTERIOR APPROACH No enlargement
POSTERIOR APPROACH No discrete nodules, nontender
0.30–5.00mIU/L
FREE T
4
>23pmol/L
11–23pmol/L
>>
314 PHYSICAL EXAMINATION
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>>
HEALTH HISTORY
FREE T
3
UNIT 2
CRP 80mg/L
>6.7pmol/L
Nuclear medicine scan of thyroid gland with uptake: Multiple pinhole images of the thyroid show a mild diffuse
goitre. The thyroid is mildly enlarged. The lobes are biconvex in conguration with homogeneous uptake of
the radionuclide throughout the parenchyma of both lobes. No discrete nodules are identied. 6- and 24-hour
radioactive uptake measurements are mildly elevated at 28.7% and 42.6%.
Impression: Mild diffuse toxic goitre
EVALUATION AND CLINICAL
REASONING FOR CASE STUDY
The assessment and clinical decisions you make should reect
your scope of practice. For example, advanced practice health
professionals, such as nurse practitioners and remote area nurses
with endorsement, may be able to make diagnostic decisions and
prescribe medications without referring to a medical ofcer.
Fundamentally, all health professionals collect, evaluate and
act on consumer-focused health information, which will at times
include referral to, or collaboration with, other healthcare team
members. Nurses assess consumer responses to interventions
and determine when to escalate key changes in a consumer’s
condition. The clinical reasoning cycle provides health professionals with a framework to consider all this information in a
meaningful way for planning consumer care. These phases
are stepped out below, and draw on information presented and
collected during the health history and physical examination. We
then work through the cycle components that are relevant to this
case study (cycle components are bolded).
For Samuel Norris, the signicant data that needs to be
considered includes the following.
Collecting cues/information
Recall and Review: In the rst instance you will need to reect
on what you know about hyperthyroidism. This is characterised
by hyperactivity and enlargement of the thyroid gland. There are
a number of causes of hyperthyroidism, and the most common is
Graves’ disease. In this case scenario, Samuel Norris has been
diagnosed with Graves’ disease. This is an autoimmune disease of
unknown aetiology in which the body’s own immune system causes
the thyroid gland to produce excess thyroid hormone. Antibodies
to the thyroid stimulating hormone (TSH) receptor sites develop in
individuals, causing the thyroid gland to release either T
both of these. Clinical signs develop as a result of the excessive
release of thyroid hormones, in which remissions and exacerbations
are common patterns even when the person is treated.
Chief complaint and history of present illness
(subjective data)
> States ‘I just haven’t felt right for the past couple of months’.
> 9 months previously, noted tonsillar enlargement, subsequently
diagnosed with squamous cell carcinoma of the tonsils.
Treated with surgical removal and 6-week course of
radiation therapy
or T4 or
3
3.5–6.7pmol/L
<12mg/L
> Over the last 2 months, has experienced myalgia and
generalised weakness
> Weight loss 4kg since surgery
> Verbalised concern about present health status and the lack of
sick leave remaining if illness continues
Processing information
Interpret: These symptoms and details of history outline the scope
of the issue for this consumer and how it affects their wellbeing
and ability to self-manage.
Health maintenance activities
> Diet is poor (fast-foods, fried food, regular coffee), on the run,
but wants to do better with diet
> Limited exercise but aware more is desirable
> Other issues: Smoker (8–10 cigarettes/day, occasional cigar),
alcohol each night (2 beers)
Physical assessment
> Enlarged lymph nodes noted
> Thyroid functioning tests elevated
> Elevated CRP (indicates inammation)
> Bruits detected in the thyroid gland
> Nuclear scan ndings indicate mild diffuse goitre
> Elevated BP (for past 10 years, medication controlled)
> Smoker
> Respiration rate 30/minute
Interpret, Discriminate, Infer and Predict: The signicance of
these ndings indicate that Samuel Norris has Graves’ disease,
which requires medical and long-term follow-up and management.
He also has a high cardiovascular risk factor prole, which
will necessitate long-term education and behavioural lifestyle
management changes.
Putting it all together – synthesise information
The role of the nurse in this case is to work with the medical
practitioners to ensure Samuel fully understands the nature and
extent of his current health problem and the lifelong management
required. The medical ofcer will review and prescribe initial
medication treatment for Samuel. Samuel will be referred to a
specialist endocrinologist for further consideration of his medical
management. Diagnosis was conrmed through review of thyroid
functioning tests (decreased TSH levels, all other thyroid function
tests increased) and radioactive iodine uptake investigation
(greater uptake of radioactive iodine noted).
HEAD, NECK AND REGIONAL LYMPH NODES 315
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Care options centre on specialist medical staff deciding the
most appropriate treatment pathway for Samuel – there is no
single treatment option for Samuel. This may include medication
management to reduce the production of thyroxine (preferred
option, pending situation); radiation, using radioactive iodine
therapy; or surgical intervention involving partial or full removal of
the thyroid gland.
Actions based on assessment ndings
Other areas that need to be considered for Samuel include:
1 Cardiovascular risk factor modication: given Samuel’s high
risk-factor prole it is critical that the nurse provides education,
referral and support on how to approach risk-factor reduction.
Samuel will need to target smoking – smoking cessation; diet –
encourage a balanced healthy diet; exercise – undertaking some
form of physical exercise at least 5 times per week.
CHAPTER RESOURCES
REVIEW QUESTIONS
For answers to these questions, see Answer section at the end of
the book.
1. The nurse is conducting an admission health history of a
consumer and asks about family health history. The nurse
recognises which of the following pathologies to be familial
conditions of the head and neck? Select all that apply.
a. Hyperthyroidism
b. Sinusitis
c. Migraines
d. Torticollis
e. Bell’s palsy
2. The posterior triangle of the neck is formed by the:
a. Mandible, trachea and sternocleidomastoid muscle
b. Omohyoid muscle, trachea and trapezius muscle
c. Sternum, sternocleidomastoid muscle and mandible
d. Sternocleidomastoid muscle, trapezius muscle and the
base of the clavicle
3. Adam, a 23-year-old male, presents to the emergency
department with a long history of allergic rhinitis. What
physical examination ndings might Adam exhibit? Select all
that apply.
a. Dry, dull facial skin
b. Round and swollen face
c. Immobile and expressionless face
d. Excess hair on the jaw and upper lip
e. Darkened areas beneath the eyes
f. Transverse nasal crease
4. While inspecting a consumer’s face, you note their slanted
eyes with inner epicanthal folds; a short, at nose; and a thick,
protruding tongue. What condition do these ndings suggest?
a. Hydrocephalus
2 Anxiety and concern about limited sick leave time available at
work: Due to the ongoing sick role and lengthy time off work,
the nurse should give Samuel the opportunity to express his
feelings about this and provide information about contacting
his employer regarding present illness in the view to working
out a return-to-work plan. Provide support options through
pastoral care, counselling and other social support structures.
3 Broader education about living with thyroid disease, how to
manage this, with particular emphasis on compliance with
medication and modications to present lifestyle, will
be important.
The nal step in the process is accurate documentation. The
nurse must document ndings, referrals, interventions, advice and
education given. The consumer would continue to have ongoing
long-term management and follow-up by specialist medical staff in
collaboration with Samuel’s general practitioner.
b. Craniosynostosis
c. Bell’s palsy
d. Down syndrome
5. Amelie reports feeling intermittent muscle spasms and facial
grimacing. Which of these conditions is she most likely
experiencing?
a. Hypothyroidism
b. Hyperthyroidism
c. Hypoparathyroidism
d. Hyperparathyroidism
6. Which of the following assessment ndings describes the
consumer with Cushing syndrome?
a. Red cheeks, increase in hair on the upper lip, large cheeks
b. An abnormally wide distance between the eyes
c. Facial skin that is shiny, contracted and hard
d. Sunken eyes and hollow cheeks
7. Risk factors for thyroid cancer include:
a. Thyroid adenoma, male sex, diet high in sodium
b. Exposure to nuclear fallout, female sex, diet high
in phosphates
c. History of thyroid radiation, male sex, diet low in potassium
d. Genetics, female sex, diet low in iodine
8. While inspecting a consumer, you note that the consumer’s
neck deviates sharply to the left. The consumer also has a
prominent left sternocleidomastoid muscle. What may be
causing this consumer’s condition?
a. Osteoarthritis
b. Acute spasm
c. Trigeminal neuralgia
d. Thyroid cancer
CHAPTER 9
Соседние файлы в папке Библиотека им академика М.И. Перельмана