ATI head, neck, and neuro

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

Make the client NPO Assess the clients orientation Obtain the clients vital signs

A nurse is preparing to inspect the outer ears have a client who has been in a motor vehicle crash. The nurse should identify that which of the following findings indicate the client might have a skull fracture?

Bloody drainage

A nurse is assessing a client who has a lump on her neck. Which of the following question should the nurse asked 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 an older clients mouth. The nurse should identify that which of the following is an expected variation for this client?

Darkening of the mucosa

A nurse is performing a head to toe assessment on a client and notes a lump on the interior portion of their neck. The nurse should identify that this fine they 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 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 clients electronic health record (EHR) should the nurse document this finding?

Encounter

A nurse is obtaining a clients health history. Which of the following question should the nurse ask to obtain a focused history of the ears?

Have you had trouble hearing? Do you ever lose your balance? Have you ever use hearing aids? Do you have ringing in your ears?

A nurse is admitting a client who had a stroke. Which of the following action should the nurse take?

Keep the clients bed in the lowest position

A nurse is assessing a client head. Which of the following should the nurse identify as an unexpected finding?

Oval white patches in the clients hair. A lesion on the clients scalp. Protrusion of the clients head. Adema around the clients eyes.

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

Review of systems

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 and older client about health promotion. The nurse should instruct the client to have which of the following examination performed on a regular basis?

Vision screening every year Dental examination every six months

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 preparing to assess a clients 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 clients lower eyelids. Gently pull the client skin down to the top edge of the pony orbital rim. Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

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 indicate which of the following conditions?

Central nervous system disorder

A nurse is assessing the eye of a client who experienced a sub conjunctival hemorrhage as a result of vomiting. Which of the following findings should the nurse expect?

Defined reddened area of the sclera

A nurse is preparing to palpate a client's sinuses. Identify the sequence the nurse should follow when taking the following actions.

Position the thumbs on the supra orbital ridge just below the clients eyebrows to assess the clients 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. Position the thumbs below the clients cheekbones with fingers along the clients head to assess the clients maxillary sinuses. Apply firm upward pressure and ask the client if they detect tenderness or pain.