ATI HEALTH ASSESS: HEAD, NECK, NEUROLOGICAL

a nurse is inspecting the sinuses of a client who has allergies. which fo the following should the nurse expect

pale muscosa

a nurse is caring for a client who had a suspected stroke. which of the following actions should the nurse take

-NPO -asses the clients orientation -obtain vital signs

a nurse is preparing to asses a client's conjunctiva. identify the sequence the nurse should follow when taking the following actions

-apply examination gloves -instruct the client to look up -place the thumbs below each of the client's lower eyelids -gently pull the client's skin down to the top edge of the bony orbital rim -inspect the color and condition of the conjunctiva and scerla, noting any color change, swelling, drainage, or lesions

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

-vision every year -dental 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?

beefy red tongue

a nurse is preparing to inspect the outer ear 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

bloody drainage

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

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?

darkening of the mucosa

a nurse is assessing the eye of a client who experienced a subconjunctival hemorrhage as a result of vomitting. which of the following findings should the nurse expect

defined reddened area of the sclera

a nurse is performing a head assessment on a client. after checking the clients vision, the nurse notes the client has difficulty reading fine print. in which of the following sections of the clients electronic health record should the nurse document finding

review of systems

a nurse is performing a head to toes 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 condition

thyroid disorder

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

transparant layer that covers the iris and pupil

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 clients electronic health record should the 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 the client's bed in the lowest position

a nurse is assessing the mouth of a client who has candidiasis, an oral 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 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 assassin a client's head. which of the following should the nurse identify as an unexpected finding

-oval white patches on head -lesion on scalp -protrusion on clients head -edema around eyes

a nurse is preparing to palpate a clients sinuses. identify the sequence the nurse shoulf followi when taking the following actions

-positon the thumbs on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses -firmly press upward on the ridge and make sure not to apply pressure to the client's eyes -ask the client if they detect tenderness or pain -positon the thumbs below the client's cheekbones with fingers alongside the clients head to assess the client's maxillary sinuses -apply firm, upward pressure and ask the client if they detect tenderness or pain

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 -do you ever lose your balance -have you ever used a hearing aid -do you have ringing in your ears