Head, Neck, and neurological ATI

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.

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 is the first step. When assessing the client's conjunctiva, examination gloves need to be applied first because the nurse will come in contact with the client's mucous membranes and contact precautions should be used. 2. instructing the client to look up is the second step. Instructing the client to look up allows the nurse to inspect a larger area of the conjunctiva. 3. Place the thumbs below each of the client's lower eyelids is the third step. Then, the nurse should place their thumbs below each of the client's lower eyelids, which places the nurse's thumbs in the best position for the next step. 4. Gently pull the client's skin down to the top edge of the bony orbital rim is the fourth step. Next, the nurse should gently pull the client's skin down to the top edge of the bony orbital rim. This allows the nurse to better see the client's conjunctiva. 5. Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions is the fifth step. Lastly, the nurse should inspect the color and condition of the conjunctiva 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 Beefy Red Tongue The nurse should identify that a client who has a vitamin B12 insufficiency can have a smooth, dark, or swollen tongue.

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 The nurse should keep the client's bed in the lowest position closest to the floor. This allows the client to get out of bed easier with assistance.

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

Vision screening every year is correct. The nurse should instruct the client to have their vision screened every year after the age of 60. Dental examination every 6 months is correct. The nurse should instruct the client to have a dental examination and cleaning every 6 months.

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 The nurse should expect white patches on the client's tongue. This is an indication of candidiasis, which is an oral infection known as thrush.

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 The nurse should identify yellowing of the sclera can indicate that the client has liver disease.

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. The nurse should identify that a client who has experienced a subconjunctival hemorrhage will have a defined reddened area of the sclera. This results from leakage of blood outside the blood vessels due to increased pressure within the eye during vomiting.

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 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

The nurse should identify that a client who has allergies can have pale mucosa, as well as clear discharge.

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

The nurse should identify that the transparent layer that covers the iris and pupil is the cornea.

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. The nurse should identify that an anterior lump on the client's neck can indicate that the client has a thyroid disorder.

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?

"Have you had trouble hearing?" is correct. The nurse should ask the client about difficulties hearing when obtaining a focused history of the ears. The ears provide two main functions: hearing and equilibrium. "Do you ever lose your balance?" is correct. The nurse should ask the client if they ever lose their balance when obtaining a focused history of the ears. If the client answers yes, it could indicate that they have an inner ear disorder. "Have you ever used hearing aids?" is correct. The nurse should ask the client if they have ever used hearing aids when obtaining a focused history of the ears. The use of hearing aids is important for the nurse to know and document as part of the focused history of the ears. "Do you have ringing in your ears?" is correct. The nurse should ask the client if they have ringing in their ears, or tinnitus when obtaining a focused history of the ears. If the client answers yes, it could indicate that they have an inner ear problem.

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

1. Positioning the thumbs on the supraorbital ridge just below the client's eyebrows to assess the client's frontal sinuses is the first step. When palpating a client's sinuses, the nurse should position their 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 is the second step. Next, the nurse should firmly press upward on the ridge and make sure not to apply pressure to the client's eyes. 3. . Asking the client if they detect tenderness or pain is the third step. Then, the nurse should ask the client if they detect tenderness or pain. If the client detects pain, the nurse should ask the client about the quality, location, and symmetry of the pain, and document the findings. 4. Positioning the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses is the fourth step. Next, the nurse should position their 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 is the fifth step. Finally, the nurse should apply firm, upward pressure and ask the client if they detect tenderness or pain. If the client detects pain, the nurse should ask the client about the quality, location, and symmetry of the pain, and document the findings.

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 on the Tongue 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 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. The nurse should identify that difficulty swallowing or a headache can indicate that the client has a central nervous system disorder.

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)

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. 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 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?" 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. 2."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. 3."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. 4."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 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

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.