Head, Neck, and Neurological Test

A nurse is inspecting the sinuses of a client who has allergies. Which of the following findings should the nurse expect?

Pale mucosa, clear discharge

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 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 hearing aids?" "Do you have ringing in your ears?"

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 conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

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 supraorbital ridge just below the client's eyebrows to assess the client's frontal sinuses. 2. Firmly press upward on the ridge and make sure not to apply pressure to the client's eyes. 3. Ask the client if they detect tenderness or pain. 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 they detect tenderness or pain.

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 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; subjective data the nurse is obtaining from the client and the purse 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?

Keep the client's bed in the lowest position; allows client to get out of bed easier with assistance.

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

Make the client NPO; nurse should have the client's swallowing ability tested to prevent aspiration due to dysphasia. Assess the client's orientation; baseline assessment at the time of suspected stroke for comparison to previous orientation and any future changes. Obtain the client's vital signs; baseline reference and comparison. VS include heart function and BP which are contributors to strole events.

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; can indicate pediculus humanus capitus (lice) A lesion on the client's scalp; indicate a skin disorder or infection Protrusion of the client's head; trauma to the head Edema around the client's eyes, cheeks, or face; indicate infection trauma, or a heart disorder

A nurse is performing a head and neck assessment on a client. After checking the client's vision, the nurse notes the client has difficulty reading fine print. In which of the following sections of the client's electronic health record (EHR) should the nurse document this finding?

Review of systems; contains objective data that the nurse obtains while performing the assessment.

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

Transparent layer that covers the iris and pupil.

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 screening every year after the age of 60. Dental examinations and cleaning every 6 months

A nurse is assessing the mouth of a client who has candidiasis, an oral fungal infection (thrush). 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 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 preparing to inspect the outer ears 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?

Clear, watery or bloody drainage

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; due to the lack of saliva and dryness of the mouth.

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 the sclera; results from leakage of blood outside the blood vessels due to increased pressure within the eye during vomiting.