ATI Head, Neck, Neurological

Correct terms: -"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 assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (SATA)

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

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions. (Move steps into the box on the right. All steps will be used)

Beefy red tongue

A nurse is assessing the mouth of a client who has a vitamin b12 insufficiency. Which of the following findings should the nurse expect?

Keep the client's bed in the lowest position

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

Correct terms: -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 assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (SATA)

Darkening of the mucosa (this is due to lack of saliva and dryness of the mouth in older clients)

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

Defined reddened area of the sclera

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

White patches on the tongue

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?

Correct terms: -Make the client NPO -Assess the client's orientation -Obtain the client's vital signs

A nurse is caring for a client who had a suspected stroke. Which of the following actions should the nurse take? (SATA)

Pale mucosa

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

Thyroid disorder

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?

Transparent layer that covers the iris and pupil

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

Yellow sclera

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

Correct terms: -"have you had trouble hearing?" -"do you ever lose your balance?" -"have you ever used hearing aids?" -"do you have ringing in your ears?"

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused history of the ears? (SATA)

Central nervous system disorder

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

Review of systems

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

Encounter

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 should the nurse document this finding?

Bloody drainage

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 the following findings indicates the client might have a skull fracture?

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 preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions.

Correct terms: -vision screening every year -dental examination every 6 months

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? (SATA)