Head, Neck, and neurological ATI

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

A nurse is assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect? 1. White patches not he tongue 2. Bleeding of the gums 3. Beefy red tongue 4. Petechiae of the hard palate

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? 1. Edema 2. Bloody drainage 3. yellow drainage 4. crushed skin

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. Edema around the client's ear can indicate that the client has an ear infection. Yellow drainage from the client's ear can indicate that the client has an ear infection. Crusted skin around the client's ear can indicate that the client has an ear infection.

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? 1. White patches on the tongue 2. Beefy red tongue 3. Petechiae on hard palate 4. Overgroth og gum tissue

White patches on the tongue AKA thrush A beefy red tongue, which can be smooth, dark, or swollen, can indicate that the client has a vitamin B12 insufficiency. Petechiae on the client's hard palate can indicate that the client has an infection. Overgrowth of gum tissue can indicate gingival hyperplasia.

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? 1. Defined reddened area of the sclera 2. Dropping of the eyelid 3. Cloudy pupil 4. Bulging eyes

defined reddened area of the sclera

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) 1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears? 5. Do you have a problems with nasal drainage?

1. Have you had trouble hearing? 2. Do you ever lose your balance? 3. Have you ever used hearing aids? 4. Do you have ringing in your ears? "Do you have problems with nasal drainage?" is incorrect. The nurse should ask the client if they are having problems with nasal drainage when obtaining a focused history of the sinuses.

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) 1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?" 5."Have you started taking a new medication?"

1. "Are you experiencing difficulty breathing?" 2."How long has the lump been on your neck?" 3."Is the lump causing you discomfort?" 4."Are you having difficulty swallowing?" "Are you experiencing difficulty breathing?" is correct. 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."How long has the lump been on your neck?" is correct. 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."Is the lump causing you discomfort?" is correct. 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."Are you having difficulty swallowing?" is correct. 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 caring for a client who had a suspected stroke? Which of the following actions should the nurse take? (Select all that apply) 1. Make the client NPO. 2.Assess the client's orientation. 3.Check cranial nerves I, II, and V. 4.Inspect the client's muscular symmetry. 5. Obtain the client's vital signs

1. Make the client NPO 2. Assess the client's orientation 5. Obtain the client's vital signs Make the client NPO is correct. 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. Assess the client's orientation is correct. 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.Check cranial nerves I, II, and V is incorrect. The nurse does not need to check cranial nerves I, the olfactory nerve, II, the optic nerve, and V, the trigeminal nerve, at this time. Assessment of cranial nerves could be indicated at a later time when there is a definitive diagnosis, but not when there is a suspected diagnosis of a stroke. Cranial nerve II would be the most beneficial to assess if it were indicated. Assessing cranial nerves I and V would not provide good assessment findings for a stroke.Inspect the client's muscule mass for symmetry is incorrect. A client who is suspected of having a stroke can experience potential asymmetrical muscular movements or muscle weakness. Therefore, there is no need for the nurse to inspect the client's muscle mass for symmetry.Obtain the client's vital signs is correct. 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) 1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes 5.Protrusion of the client's mastoid bone

1. Oval white patches in the client's hair 2.A lesion on the client's scalp 3.Protrusion of the client's head 4.Edema around the client's eyes Oval white patches in the client's hair is correct. The nurse should identify that oval white patches in the client's hair can indicate head lice, or Pediculus humanus capitus. A lesion on the client's scalp is correct. The nurse should identify that a lesion on the client's scalp can indicate a skin disorder or infection. Protrusion of the client's head is correct. The nurse should identify that protrusion of the client's head can indicate recent trauma to the head. Edema around the client's eyes is correct. 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 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 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) 1.Vision screening every year 2.Hearing test every 5 years 3.Dental examination every 6 months 4.Skin cancer screening every 2 years 5.Neurological check every 3 months

1.Vision screening every year 3.Dental examination every 6 months Vision screening every year is correct. The nurse should instruct the client to have their vision screened every year after the age of 60. Hearing test every 5 years is incorrect. The nurse should instruct the client to have their hearing tested at least every 3 years after the age of 50.4 Dental examination every 6 months is correct. The nurse should instruct the client to have a dental examination and cleaning every 6 months. Skin cancer screening every 2 years is incorrect. The nurse should instruct the client to have a skin cancer screening every year after the age of 40. Neurological check every 3 months is incorrect. A neurological check should only be recommended by the provider. A neurological check is typically recommended if there has been a change in the client's cognition or the client has a neurological 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? 1.Yellowing of the hard palate 2. Red spots on the hard palate 3. White patches not he Tonge 4. Darkening of the mucosa

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 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? 1. Encounter 2. Vital signs 3. Patient information 4. Allergies and home medications

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 admitting a client who has had a stroke. Which of the following actions should the nurse take. 1. Keep the bedside table at the end of the client's bed 2. Place a towel not he client's bathroom floor 3. Raise the four side rails of the clients's bed 4. Keep the client's bed in the lowest position

Keep client's bed in the lowest position 3 is wrong bc The nurse should raise two to three side rails of the client's bed at most. Raising all four side rails is a restraint and can be a safety risk to the client.

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect? 1. Ptosis of an eyelid 2.Yellow sclera 3.Edema of the eyelids 4.Reddened conjunctiva

Yellow sclera

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? 1. Chest disorder 2. Thyroid disorder 3. Musculoskeletal disorder 4. Central nervous system disorder

central nervous system disorders

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect? 1. Pale mucosa 2. Bright red mucosa 3. Green discharge 4. Yellow discharge

pale mucosa *The nurse should identify that a client who has allergies can have pale mucosa, as well as clear discharge. Bright red mucosa is an indication that the client has an upper respiratory infection. Green discharge is an indication that the client has an infection of the sinuses. Yellow discharge is an indication that the client has an infection of the sinuses.

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? 1. Vital signs 2. Review of system 3. Allergies and home medications 4. Patient information

review of systems 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 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? 1. Infection 2. Cancer 3. Thyroid disorder 4. Chest disorder

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? 1. Outer layer of the eyeball 2. Mucous membrane that lines the eyeball 3. Transparent layer that covers the iris and pupil 4. Colored portion in the center of the eye

transparent layer that covers the iris and pupil