Head, Neck, and Neurological

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

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?

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. Asses the client's orientation C. Check cranial nerves I, II, and V D. Inspect the client's muscular symmetry E. Obtain the client's vital signs

A. Make the client NPO B. Asses the client's orientation E. Obtain the client's vital signs

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

Which of the following are unexpected findings of the eyes? (Select all that apply). A. Subconjunctival hemorrhage B. Gingivitis C. Ptosis D. Thrush E. Conjunctivitis F. Entropion

A. Subconjunctival hemorrhage C. Ptosis E. Conjunctivitis F. 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? A. Chest disorder B. Thyroid disorder C. Musculoskeletal disorder D. Central nervous system disorder

D. Central nervous system disorder

Which of the following client responses requires additional investigation? A. "I've been feeling a lot of stress lately. I recently started my own business." B. "I've been too busy to fit exercise into my schedule lately." C. "Now that you mention it, I have been having headaches more frequently than I used to." D. "I've been drinking a little more than before to help me relax." E. "I take over-the-counter medicine if I'm really feeling miserable." F. "I am having some trouble with seeing things close up lately."

A, C, D, E

Place the following steps in the correct order to perform an assessment of a client's pupillary reaction to light. A. Observe the pupillary response in both eyes B. Have the client sit facing you at eye level C. Move your penlight in from the side to shine on one pupil D. Instruct the client to look at a distant object E. Darken the room F. Observe the pupils for size

B, F, E, D, C, A

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 systems C. Allergies and home medications D. Patient information

B. Review of systems

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 not he Tonge D. Darkening of the mucosa

D. Darkening of the mucosa

Which of the following areas should the technique of palpation be used as part of the assessment? A. Eye structure B. Trachea C. Tongue D. Sinus cavities

D. Sinus cavities

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions. A. Apply examination gloves B. Place the thumbs below each of the client's lower eyelids. C. Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions D. Gently pull the client's skin down to the top edge of the bony orbital rim E. Instruct the client to look up

A. Apply examination gloves E. Instruct the client to look up B.Place the thumbs below each of the client's lower eyelids. D. Gently pull the client's skin down to the top edge of the bony orbital rim C. Inspect the color and condition of the conductive and sclera, noting any color change, swelling, drainage, or lesions

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? A. White patches on the tongue B. Beefy red tongue C. Petechiae on hard palate D. Overgroth og gum tissue

A. White patches on the tongue

which of the following statements should you include in a teaching about health promotion screenings for adults? A. You should have your vision checked every 2 years B. You only need your hearing checked if you think you have a problem C. You should have a dental exam every other year D. You can decrease the frequency of screenings after the age of 60

A. You should have your vision checked every 2 years

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

When assessing the ear, which of the following is an emergency and requires immediately contacting the provider? A. Conductive hearing loss B. Bloody drainage from the ear following head trauma C. Edematous outer ear canal D. Yellow or green malodorous discharge

B. Bloody drainage from the ear following head trauma

Which of the following tools are used in an assessment of the head and neck? (Select all that apply.) A. Tape measure B. Penlight C. Examination gloves D. Stethoscope E. Doppler F. Watch with a second hand

B. Penlight C. Examination gloves

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 clients's bed D. Keep the client's bed in the lowest position

D. Keep the client's bed in the lowest position

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?"

For which of the following findings should you contact the provider? A. Clear one-sided nasal drainage in a client who fell down the stairs B. A clearly defined collection of blood in the sclera of a client who has been vomiting C. Dark yellow cerumen in the outer ear canal of a client who has been coughing D. Palpable lymph nodes in the neck of a client who has an upper respiratory infection

A. Clear one-sided nasal drainage in a client who fell down the stairs

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

C. Beefy red tongue

Which of the following statements should the nurse include in the medical record? A. The client's pupils are not equal and the left one is slow to constrict when I shine my penlight on the pupil after darkening the room. B. Pupil examination is abnormal C. Left pupil is dilated to 7mm and has a sluggish reaction to light D. The client's eyes do not look or act the same.

C. Left pupil is dilated to 7mm and has a sluggish reaction to light

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

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

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

Which of the following instructions should you include while teaching a client about actions to promote the health of their head and neck? (Select all that apply.) A. Use ear protection when attending a loud event B. Brush your teeth once a day C. Wear eye protection when cutting the grass D. Wear a bike helmet if you are going to participate in a bike race E. Limit music volume when using headphones.

A. Use ear protection when attending a loud event C. Wear eye protection when cutting the grass D. Wear a bike helmet if you are going to participate in a bike race E. Limit music volume when using headphones.

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

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions. A. Ask the client if they detect tenderness or pain is the third step B. Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses. C. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step D. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step E. Apply firm, upward pressure and ask the client if hey detect tenderness or pain

C. Position the thumbs on the supra orbital ridge just below the client's eyebrows to assess the clients frontal sinuses is the first step D. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes is the second step A. Ask the client if they detect tenderness or pain is the third step B. Position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses. E. Apply firm, upward pressure and ask the client if hey detect tenderness or pain

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

Which of the following questions should you ask the client when assessing for an orientation deficit? (Select all that apply). A. What is the date? B. What is your birthday? C. Do you know why you are here? D. Who is the president? E. What time is it? F. Where are you?

B. What is your birthday? C. Do you know why you are here? D. Who is the president? F. Where are you?

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

Which of the following statements would be most appropriate to include in the medical record? A. The left side of the mouth is noted to be dropping. Speech is slurred but is understandable with appropriate word choices. B. Mouth is asymmetric and I am having trouble understanding what he is saying. C. The client is having trouble speaking probably due to his drooping mouth. D. The client is having a stroke.

A. The left side of the mouth is noted to be dropping. Speech is slurred but is understandable with appropriate word choices.