Head, neck, and neurological Test

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 difficulty breathing?"

"Is the lump causing you discomfort?"

"Have you started taking a new medication?"

"How long has the lump been on your neck?"

"Are you having difficulty swallowing?"

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 difficulty breathing?"

"Is the lump causing you discomfort?"

"Have you started taking a new medication?"

"How long has the lump been on your neck?"

"Are you having difficulty swallowing?"

"Are you experiencing difficulty breathing?"

"Is the lump causing you discomfort?"

"How long has the lump been on your neck?"

"Are you having difficulty swallowing?"

sA 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

Drooping of the eyelid

Cloudy pupil

Bulging eyes

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.

Drooping of the eyelid can indicate nerve damage. 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 cloudy pupil is an indication that the client has a cataract. 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.

Bulging eyes, or exophthalmos, is a manifestation of hyperthyroidism. 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 assessing the mouth of a client who has a vitamin B12 insufficiency. Which of the following findings should the nurse expect?

White patches on the tongue

Bleeding of the gums

Beefy red tongue

Petechiae of the hard palate

The nurse should identify that a client who has a vitamin B12 insufficiency can have a smooth, dark, or swollen tongue.

Petechiae on the client's hard palate can indicate an infection.

Bleeding of the client's gums can indicate gingivitis.

White patches on the client's tongue can indicate candidiasis, an oral infection known as thrush.

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?

Overgrowth of gum tissue

Beefy red tongue

Petechiae on hard palate

White patches on the tongue

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

Overgrowth of gum tissue can indicate gingival hyperplasia.

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. Use all the steps.)

Instruct the client to look upward.

Gently pull the client's skin down to the top edge of the bony orbital rim.

Apply examination gloves.

Place the thumbs below each of the client's lower eyelids.

Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

Apply examination gloves.

Instruct the client to look upward.

Place the thumbs below each of the client's lower eyelids.

Gently pull the client's skin down to the top edge of the bony orbital rim.

Inspect the color and condition of the conjunctiva and sclera, noting any color change, swelling, drainage, or lesions.

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?

Edema around the ear

Watery, clear drainage

Yellow drainage

Crusted skin

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 preparing to palpate a client's sinuses. 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. Use all the steps.)

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 on the supra orbital ridge just below the client's eyebrows to assess the client's frontal sinuses.

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 tenderness or pain.

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 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 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 tenderness or pain.

A nurse is performing a head-to-toe assessment on a client. Which of the following assessment findings may indicate that the client has a thyroid disorder?

Beefy red tongue

Swollen lymph nodes

Lump on the anterior portion of their neck

Lip color is darker than surrounding skin

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

Visible or swollen lymph nodes can indicate that the client may have an infection or cancer.

Lip color is darker than surrounding skin is an expected finding.

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

Edema around the client’s eyes

A lesion on the client's scalp

Protrusions on the client’s head

Protrusion of the client's mastoid bone

Oval white patches in the client's hair

The nurse should identify that edema around the client's eyes, cheeks, or face can indicate infection, trauma, or a heart disorder.

The nurse should identify that protrusions on the client's head can indicate recent trauma to the head.

The nurse should identify that a lesion on the client's scalp can indicate a skin disorder or infection.

The nurse should identify that oval white patches in the client's hair can indicate head lice, or pediculus human capitis.

Protrusion of the client's mastoid bone behind the client's ear is an expected finding

A nurse is assessing a client's mouth. The nurse should identify that which of the following is an expected finding?

Yellowing of the hard palate

Red spots on the hard palate

White patches on the tongue

Large vein on the ventral surface of the tongue

The nurse should identify that a large vein on the ventral surface of the tongue is an expected finding.

White patches on the client's tongue can indicate candidiasis, an oral infection known as thrush

Red spots, or petechiae, on the client's hard palate can indicate an infection

Yellowing of the client's hard palate can indicate a liver disorder

A nurse is performing a head and neck assessment on a client. The client reports a high-pitched ringing in their ears. Which of the following terms should the nurse use when documenting what the client is experiencing?

Tinnitus

Strabismus

Bell's palsy

Hirsutism

The nurse should document that the client is experiencing tinnitus. Tinnitus is a high-pitched ringing in the ears.

Hirsutism is the presence of coarse facial hair on a female client, indicating a hormonal or endocrine disorder.

Bell’s palsy is weakness of the facial muscles causing asymmetry of facial features.

Strabismus is a misalignment of the axes of the eyes.

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client to obtain a focused health history of the ears?
Select all that apply.

"Do you have ringing in your ears?"

"Have you ever used hearing aids?"

"Have you had trouble hearing?"

"Do you have problems with nasal drainage?"

"Do you ever lose your balance?"

"Do you have ringing in your ears?"

"Have you ever used hearing aids?"

"Have you had trouble hearing?"

"Do you ever lose your balance?"

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

Pale mucosa

Bright red mucosa

Green discharge

Yellow discharge

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 and/or Yellow discharge is an indication that the client has an infection of the sinuses.

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

Outer layer of the eyeball

Mucous membrane that lines the eyeball

Transparent layer that covers the iris and pupil

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.

The outer layer of the eyeball is the sclera, which is the white portion of the eye surrounding the iris.

The mucous membrane that lines the eyeball is the conjunctiva.

The colored portion in the center of the eye is the iris, which regulates the amount of light entering the lens of the eye.

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?

Vital signs

Review of systems

Allergies and home medications

Patient information

The nurse should include the client's report of "vision changes, especially when reading fine print" as part of the review of systems 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.

Patient information is initial admission information, such as the client's name, address, date of birth, Social Security number, admitting provider, and health insurance information, and should be documented in this section of the client's EHR

The nurse should document vital signs, oxygen saturation, and any measurable data in this section of the client's EHR.

A nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse take?
Select all that apply.

Assess orientation

Assess for strabismus

Assess muscle strength

Obtain vital signs

Make the client NPO

The nurse should make the client NPO and have the client’s swallowing ability tested to prevent the risk of aspiration due to impaired swallowing.

The nurse should assess the client’s baseline orientation at the time of the suspected stroke to allow for a comparison to previous orientation and future changes.

The nurse should assess the client’s muscle strength. The client who has had a stroke may have hemiparesis or hemiplegia, leading to decreased muscle strength on one or both sides.

The nurse should obtain vital signs at the time of the suspected stroke for a baseline reference and comparison. The vital signs will indicate heart function, blood pressure which are contributors to stroke events.

Strabismus is the misalignment of the axes of the eyes in which one or both eyes either turn inward toward the nose or outward toward the ear and is not a manifestation of a stroke.

A nurse is preparing to assess the eyes of a client who has liver disease. Which of the following findings should the nurse expect?

Ptosis of an eyelid

Yellow sclera

Edema of the eyelids

Reddened conjunctiva

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

Edema of the eyelids can indicate heart failure.

A reddened conjunctiva, or conjunctivitis, can indicate inflammation or an infection.

The nurse should identify that ptosis, or drooping, of an eyelid can be congenital, related to the aging process, or the result of an injury.

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

Keep the bedside table at the end of the client's bed.

Place a towel on the client's bathroom floor.

Raise the four side rails of the client's bed.

Keep the 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 more easily with assistance.

Raising all four side rails is a restraint and can be a safety risk to the client.

The nurse is performing a neurologic assessment and planning to assess light touch. What equipment will the nurse use?

Sharp end of a paperclip

Reflex hammer

Wisp of cotton

Stethoscope

Wisp of cotton

What do deep tendon reflexes show clinically? The patient is able to follow commands The brain is intact The elbows, wrists, knees, and ankles are flexible The peripheral nervous system is intact

The peripheral nervous system is intact

What should the nurse assess to test the function of the occipital lobe? Ability to read Communication Impulses from the ear Tactile sensation

Ability to read

Which tests are appropriate for a nurse to perform to test cranial nerve VII? Smile, frown, show teeth, and puff out cheeks Gag reflex, rise of the uvula, and ability to swallow Clench the teeth, light touch, and sharp/dull discrimination Shoulder shrug and head turning

Smile, frown, show teeth, and puff out cheeks

Which part of the brain controls the vital functions of temperature, heart rate, blood pressure, and sleep? Cerebral cortex Hypothalamus Medulla Brain stem

Hypothalamus

What task should a nurse ask a client to perform to assess the function of cranial nerve XI? shrug shoulders against resistance move tongue side to side swallow water walk in heel-to-toe fashion

shrug shoulders against resistance

Match the cranial nerve with its type of impulse.

- Glossopharyngeal

- Trochlear

- Vestibulocochlear

- Trigeminal

A. Sensory

B. Both sensory and motor

C. Neither sensory nor motor

D. Motor

B. Glossopharyngeal

D. Trochlear

A. Vestibulocochlear

B. Trigeminal

The nurse is assessing the neurologic system. What assessment techniques are used to determine that the body is symmetrical, there are no extra movements, and the gait is steady?

Interview

Auscultation

Inspection

Palpation

Inspection

The nurse is assessing pupils, squinting, moving eyes side to side, and blinking. What cranial nerves are responsible? Select all that apply.

Abducens

Trochlear

Occulomotor

Optic Facial

Trochlear Occulomotor Facial

How does the nurse assess for nuchal rigidity?

Ask the client to look up to ceiling to hyper extend neck

Use hands to gently push head so left ear touches left shoulder and right ear touches right shoulder to assess lateral neck mobility

Ask the client to look over left then right shoulder to assess neck rotation

Ask client to touch chin to chest and if unable the nurse assists by placing hands behind the patient's head and flexing the neck forward until the chin touches the chest, if possible.

Ask client to touch chin to chest and if unable the nurse assists by placing hands behind the patient's head and flexing the neck forward until the chin touches the chest, if possible.

How does the nurse assess cranial nerve II?

Ask client to close eyes tightly

Ask client to stick out tongue

Ask client to read the lowest line possible on the Snellen (visual) chart

Ask client to shrug shoulders against resistance

Ask client to read the lowest line possible on the Snellen (visual) chart

The nurse is assessing the neurological status of an unconscious client. The nurse should use which assessment scale?

Braden

Morse

Norton

Glasgow

Glasgow

Match the area in the brain with what it mediates.

- Wernicke's

- Broca's

- Hypothalamus

- Brainstem

- Somesthetic cortex

- Limbic

A. Speech

B. Body temperature

C. Emotion

D. Position, sense, touch

E. Auditory

F. Respirations

E. Wernicke's

A. Broca's

B. Hypothalamus

F. Brainstem

D. Somesthetic cortex

C. Limbic

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client experiences pain when clenching her teeth

The client moves her feet apart to prevent herself from falling.

The client is unable to consistently touch her finger to her nose while her eyes are close.

The client experiences pain during neck flexion and extension.

The client moves her feet apart to prevent herself from falling.

During the health history a client reports a decrease in his ability to smell. During the physical assessment, the nurse would make sure to assess which cranial nerve?

CN II

CN I

CN VII

CN IX

CN I

What would the nurse most likely find when assessing a client diagnosed with a frontal lobe contusion following a motor vehicle accident?

Blurred vision

Difficulty speaking

Loss of tactile sensation

Inability to hear high-pitched sounds

Difficulty speaking

Match the cerebral lobe in the brain with its responsibility.

Parietal lobe

Frontal lobe

Temporal lobe

Occipital lobe

A. Responsible for emotions

B. Interprets auditory stimuli

C. Interprets tactile senstations

D. Influences understanding of what was read

C. Parietal lobe A. Frontal lobe B. Temporal lobe D. Occipital lobe

An adult client has asked the nurse about actions that she can take to reduce her future risk of stroke. What health promotion activity should the nurse prioritize?

Improved coping skills

Nutritional supplementation

Smoking cessation

Annual MRI Screening

Smoking cessation

The nurse is preparing to perform the Romberg test on an adult male client.

The nurse should instruct the client to squat down as far as he is able to do so.

stand erect with arms at the sides and feet together.

touch the tip of his nose with his finger.

keep his eyes open while he bends at the knees.

stand erect with arms at the sides and feet together.

Match the definition with the term.

A. Hemiplegia

B. Quadriplegia

C. Spinal cord injury

D. Stroke (CVA)

E. Neuralgia

- An injury to the spinal cord above the level innervating the thorax that causes paralysis and paresthesia in the upper and lower extremities.

- A thrombosis in vessels perfusing the brain has cut off oxygen and one side of the face, one arm, and one leg are paralyzed.

- Pressure and subsequent inflammation have caused pain along a single nerve.

- Numbness and inability to move the legs and loss of bladder function caused by trauma and subsequent spinal cord injury.

B. An injury to the spinal cord above the level innervating the thorax that causes paralysis and paresthesia in the upper and lower extremities.

D. A thrombosis in vessels perfusing the brain has cut off oxygen and one side of the face, one arm, and one leg are paralyzed.

E. Pressure and subsequent inflammation have caused pain along a single nerve.

C. Numbness and inability to move the legs and loss of bladder function caused by trauma and subsequent spinal cord injury.