HEENT

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

1. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step 2. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step 3. Ask the client if they detect tenderness or pain is the third step 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 hey detect tenderness or pain

A nurse is assessing a client who has a lump on their neck. Which of the following questions should the nurse ask the client? (select all that apply) A. "Are you experiencing difficulty breathing?" B. "How long has the lump been on your neck?" C."Is the lump causing you discomfort?" D. "Are you having difficulty swallowing?" E." Have you started taking a new medication?"

A. "Are you experiencing difficulty breathing?" B. "How long has the lump been on your neck?" C."Is the lump causing you discomfort?" D. "Are you having difficulty swallowing?" The nurse should ask the client if they are having difficulty breathing as a result of the lump on their neck. This can lead to a medical emergency if the client's airway becomes closed. The nurse should ask the client how long the lump has been on their neck. A persistent lump can be an indication that it is malignant. The nurse should ask the client if the lump is causing discomfort. If the lump is causing discomfort, the nurse should ask the client about the location and intensity of the discomfort, and also have the client describe the discomfort to provide information for diagnostic purposes. The nurse should ask the client if they are having difficulty swallowing as a result of the lump on their neck. Dysphagia can lead to aspiration when trying to swallow, eat, or drink fluids.

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? A. Pale mucosa B. Bright red mucosa C. Green discharge D. Yellow discharge

A. Pale mucosa The nurse should identify that a client who has allergies can have pale mucosa, as well as clear discharge.

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 t the following findings indicates the client might have. Skull fracture? A. Edema B. Bloody drainage C. yellow drainage D. crushed skin

B. Bloody drainage The nurse should identify that clear, watery, or bloody drainage can indicate that the client has a skull fracture. The nurse should notify the provider immediately.

A nurse is preforming an eye assessment on a client. Which of the following should the nurse identify as the cornea of the eye? A. Outer layer of the eyeball B. Mucous membrane that lines the eyeball C. Transparent layer that covers the iris and pupil D. Colored portion in the center of the eye

C. Transparent layer that covers the iris and pupil The nurse should identify that the transparent layer that covers the iris and pupil is the cornea.

A nurse is preforming 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? A. Chest disorder B. Thyroid disorder C. Musculoskeletal disorder D. Central nervous system disorder

D. Central nervous system disorder The nurse should identify that difficulty swallowing or a headache can indicate that the client has a central nervous system disorder.

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? A. Yellowing of the hard palate B. Red spots on the hard palate C. White patches on the tongue D. Darkening of the mucosa

D. Darkening of the mucosa The nurse should identify that darkening, or hyperpigmentation, of the mucosa is an expected variation for an older adult client due to the lack of saliva and dryness of the mouth.

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? (select all that apply) A. Have you had trouble hearing? B. Do you ever lose your balance? C. Have you ever used hearing aids? D. Do you have ringing in your ears? E. Do you have a problems with nasal drainage?

A. Have you had trouble hearing? B. Do you ever lose your balance? C. Have you ever used hearing aids? D. Do you have ringing in your ears? The nurse should ask the client about difficulties hearing when obtaining a focused history of the ears. The ears provide two main functions: hearing and equilibrium. The nurse should ask the client if they ever lose their balance when obtaining a focused history of the ears. If the client answers yes, it could indicate that they have an inner ear disorder. The nurse should ask the client if they have ever used hearing aids when obtaining a focused history of the ears. The use of hearing aids is important for the nurse to know and document as part of the focused history of the ears. The nurse should ask the client if they have ringing in their ears, or tinnitus, when obtaining a focused history of the ears. If the client answers yes, it could indicate that they have an inner ear problem.

A nurse is caring for a client who had a suspected stroke? Which of the following actions should the nurse take? (Select all that apply) A. Make the client NPO. B. Assess the client's orientation. C. Check cranial nerves I, II, and V. D. Inspect the client's muscular symmetry. E. Obtain client's vital signs

A. Make the client NPO. B. Assess the client's orientation. E. Obtain client's vital signs Although there is not a definitive diagnosis of a stroke yet, it is still important to put safety precautions into place for a suspected stroke to prevent client injury. The nurse should have the client's swallowing ability tested if a stroke has occurred to prevent aspiration due to dysphasia. The nurse should assess the client's orientation for a baseline assessment at the time of the suspected stroke for a comparison to previous orientation and any future changes. The nurse should obtain the client's vital signs at the time of the suspected stroke for a baseline reference and comparison. The vital signs will include heart function and blood pressure, which are contributors to stroke events.

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply) A. Oval white patches in the client's hair B. A lesion on the client's scalp C. Protrusion of the client's head D. Edema around the client's eyes E. Protrusion of the client's mastoid bone

A. Oval white patches in the client's hair B. A lesion on the client's scalp C. Protrusion of the client's head D. Edema around the client's eyes The nurse should identify that oval white patches in the client's hair can indicate head lice, or Pediculus humanus capitus. The nurse should identify that a lesion on the client's scalp can indicate a skin disorder or infection. The nurse should identify that protrusion of the client's head can indicate recent trauma to the head. The nurse should identify that edema around the client's eyes, cheeks, or face can indicate infection, trauma, or a heart disorder.

A nurse is preforming a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has a difficulty reading fine print. In which of the following sections of the client's electronic health record should the nurse document this finding? A. Vital signs B. Review of system C. Allergies and home medications D. Patient information

B. Review of system The nurse should document this finding in the review of systems section of the client's EHR because this section contains objective data that the nurse obtains while performing the assessment.

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? A. Ptosis of an eyelid B. Yellow sclera C. Edema of the eyelids D. Reddened conjunctiva

B. Yellow sclera The nurse should identify yellowing of the sclera can indicate that the client has liver disease.

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? A. White patches not he tongue B. Bleeding of the gums C. Beefy red tongue D. Petechiae of the hard palate

C. Beefy red tongue The nurse should identify that a client who has a vitamin B12 insufficiency can have a smooth, dark, or swollen tongue.

A nurse is preforming 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? A. Infection B. Cancer C. Thyroid disorder D. Chest disorder

C. Thyroid disorder The nurse should identify that an anterior lump on the client's neck can indicate that the client has a thyroid disorder

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? A. Defined reddened area of the sclera B. Dropping of the eyelid C. Cloudy pupil D. Bulging eyes

A. Defined reddened area of the sclera The nurse should identify that a client who has experienced a subconjunctival hemorrhage will have a defined reddened area of the sclera. This results from leakage of blood outside the blood vessels due to increased pressure within the eye during vomiting.

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? A. Encounter B. Vital signs C. Patient information D. Allergies and home medications

A. Encounter The nurse should include the client's report of "high-pitched ringing in their ears" in the encounter section of the client's EHR. This is subjective data the nurse is obtaining from the client and the purpose of the client's visit.

A nurse is teaching an older adult client about health promotion. The nurse should instruct the client to have which of the following examinations preformed on a regular basis? (Select all that apply) A. Vision screening every year B. Hearing test every 5 years C. Dental examination every 6 months D. Skin cancer screening every 2 years E. Neurological check every 3 months

A. Vision screening every year C. Dental examination every 6 months The nurse should instruct the client to have their vision screened every year after the age of 60. The nurse should instruct the client to have a dental examination and cleaning every 6 months.

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? A. White patches on the tongue B. Bleeding of the gums C. Beefy red tongue D. Petechiae of the hard palate

A. White patches on the tongue The nurse should expect white patches on the client's tongue. This is an indication of candidiasis, which is an oral infection known as thrush.

A nurse is admitting a client who has had a stroke. Which of the following actions should the nurse take. A. Keep the bedside table at the end of the client's bed B. Place a towel not he client's bathroom floor C. Raise the four side rails of the client's bed D. Keep the client's bed in the lowest position

D. Keep the client's bed in the lowest position The nurse should keep the client's bed in the lowest position closest to the floor. This allows the client to get out of bed easier with assistance.

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions

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 conductive and sclera, noting any color change, swelling, drainage, or lesions