Page 367 - Saunders Comprehensive Review For NCLEX-RN

3. Neck
a. Inspect for symmetry of accessory neck
muscles.
b. Assess range of motion.

c. Test cranial nerve XI (spinal

accessory nerve) to assess muscle
strength: Ask the client to push against
resistance applied to the side of the
chin (tests sternocleidomastoid
muscle); also ask the client to shrug the
shoulders against resistance (tests
trapezius muscle).
d. Palpate the trachea: It should be
midline, without any deviations.
e. Thyroid gland: Inspect the neck as the
client takes a sip of water and
swallows (thyroid tissue moves up
with a swallow); palpate using an
anterior-posterior approach (usually
the normal adult thyroid cannot be
palpated); if it is enlarged, auscultate
for a bruit.
4. Lymph nodes
a. Palpate using a gentle pressure and a
circular motion of the finger pads.
b. Begin with the preauricular lymph
nodes (in front of the ear); move to the
posterior auricular lymph nodes and
then downward toward the
supraclavicular lymph nodes. Lymph
nodes in the head and neck area to be
palpated include preauricular,
postauricular, tonsillar,
submandibular, submental, anterior
cervical chain (superficial and deep),
posterior cervical chain,
supraclavicular, and infraclavicular.
c. Palpate with both hands, comparing the
2 sides for symmetry.
d. If nodes are palpated, note their size,
shape, location, mobility, consistency,
and tenderness.
5. Client teaching: Instruct the client to notify the

primary health care provider (PHCP) if persistent
headache, dizziness, or neck pain occurs; if swelling

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