ATI - Head Neck, & Neurological

A nurse is preparing to palpate a clients sinuses. Identify the sequence the nurse should follow when taking the following action

1)Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses 2)Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes 3)Ask the client if they detect tenderness or pain 4)Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses 5)Apply firm, upward pressure and ask the client if they detect tenderness or pain

A nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a results of vomiting. Which of the following findings should the nurse expect?

Defined reddened area of the sclera

A nurse is performing an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye?

Transparent layer that covers the iris and pupil

A nurse is preparing to inspect the outer ears of a client who has been in a motor-vehicle crash. The nurse should identify that which of following findings indicates the client might have skull fracture?

Bloody Drianage

A nurse is performing a head to toe assessment on a client and notes a lump on the anterior portion of their neck. The nurse should identify that this finding can indicate which of the following conditions?

Thyroid Disorder

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?

Pale Mucosa

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client?

"Are you experiencing difficulty breathing?" "How long has the lump been on your neck?" "Is the lump causing you discomfort?" "Are you having difficulty swallowing?"

A nurse is obtaining a clients health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears?

"Do you have ringing in your ears?" "Do you ever lose your balance?" "Have you had trouble hearing? ""Have you ever used hearing aids?"

A nurse is assessing the mouth of a client who has vitamin B12 insufficiency. Which of the following findings should the nurse expect?

Beefy red tongue

A nurse is performing a focused assessment on a client who reports having difficult swallowing and continuous headache. The nurse should identify that these findings can indicate which of the following conditions?

Central nervous system disorder

A nurse is assessing an older adult clients mouth. The nurse should identify that which of the following is an expected variation for this client?

Darkening of the mucosa

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations performed on a regular basis?

Dental examination every 6 months Vision screening every year

a nurse is performing a head and neck assessment on a client. the client reports a high-pitched ringing in their ears. In which of the following sections of the client's electronic health record EHR should the nurse document this finding?

Encounter

A nurse is admitting a client who had a stroke. Which of the following actions should the nurse take?

Keep the clients bed in the lowest position.

A nurse is caring for client who has a suspected stroke. Which of the following actions should the nurse take?

Make the client NPO Assess the client's orientation Obtain the client's vital signs

A nurse is assessing a clients head. Which of the following should the nurse identify as an unexpected finding?

Oval white patches in the client's hair A lesion on the client's scalp Protrusion of the client's head Edema around the client's eyes

A nurse is performing a head and neck assessment on a client. After checking the clients vision, the nurse notes the clients has difficulty reading fine print. Which of the following sections of the clients EHR should the nurse document this finding?

Review of systems

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection. Which of the following findings should the nurse expect?

White Patches on the tongue

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following finding should the nurse expect?

Yellow Sclera

A nurse is preparing to assess a clients conjunctiva. Identify he sequence the nurse should follow when taking the following action.

1) Apply examination gloves 2) Instruct the client to look up 3)Place the thumbs below each of the client's lower eyelids 4)Gently pull the client's skin down to the top edge of the bony orbital rim 5)Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions