Head, Neck, & Neurological Test - ATI

A nurse is preparing to assess a client's conjunctiva. Identify the sequence the nurse should follow when taking the following actions. (Move the steps into the box on the right, placing them in the selected order of performance.)

Apply gloves, instruct the client to look up, place thumbs below each of the client's lower eyelids, gently pull the client's skin down, and inspect the color & condition of the conjunctiva & sclera, noting any color change, swelling, drainage, or lesions.

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.)

"Are you experiencing any 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 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 focused assessment on a client who reports having difficulty swallowing & a continuous headache. The nurse should identify that these findings can indicate which of the following conditions?

Central Nervous system disorder

A nurse is assessing an older client's 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 & 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

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.

A nurse is assessing a client's head. Which of the following should the nurse identify as an unexpected finding? (Select all that apply.)

Oval white patches in the client's hair, a lesion on the client's scalp, protrusion of the client's head, and edema around the client's 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 & 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

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? (Select all that apply.)

Vision screening every year, dental exam 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?

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 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.)

"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 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?

Bloody drainage

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

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

Make the client NPO, assess the client's orientation, & obtain the client's vital signs.

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 client's eyebrows to assess the client's frontal sinuses, firmly press upward on the ridge, ask the client if they detect any tenderness or pain, position the thumbs below the client's cheekbones with fingers alongside the client's head to assess the client's maxillary sinuses, & apply firm, upward pressure and ask the client if they detect any tenderness or pain.

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 & the pupil