212 Head, neck, and neuro ATI

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?

- have you had trouble hearing -ever lose your balance -used hearing aids -ringing in your eyes

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 assessing a client's 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

questions to ask when assessing orientation deficit?

-what is your birthday -do you know why you are here -who is the president -where are you

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

beefy red tongue

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?

bloody drainage

emergency and immediate contact to HCP for ears

bloody drainage from ear following head trauma

contact HCP

clear one sided nasal drainage in pt who fell down the stairs

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 has had a stroke. Which of the following actions should the nurse take.

keep clients bed in lowest position

which do you use palpation for the assessment?

sinus cavities

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?

thyroid disorder

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 findings should the nurse expect?

yellow sclera

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?

darkening of the mucosa

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?

defined reddened area of sclera

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 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?

review of systems

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

-make pt NPO -asses pt orientation

unexpected finding of the eye?

-subconjunctival hemorrhage -ptosis -conjunctivitis -entropion

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?

CNS disorders