head neck and neuro

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?

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Defined reddened area of the sclera

~ CORRECT

My Answer

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

INCORRECT

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.

Cloudy pupill

INCORRECT

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

INCORRECT

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?

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White patches on the tongue

INCORRECT

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

Bleeding of the gums

INCORRECT

Bleeding of the client's gums can indicate gingivitis.

Beefy red tongue

• CORRECT

My Answer

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

Petechiae of the hard palate

INCORRECT

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

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?

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Overgrowth of gum tissue

INCORRECT

Overgrowth of gum tissue can indicate gingival hyperplasia.

Beefy red tongue

INCORRECT

A beefy red tongue, which can be smooth, dark, or swollen, can indicate that the client has a vitamin B12 insufficiency.

Petechiae on hard palate

INCORRECT

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

White patches on the tongue

~ CORRECT

My Answer

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

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.)

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.

~ CORRECT

My Answer

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.

Instruct the client to look upward is the second step. Instructing the client to look up allows inspection of a larger area of the conjunctiva.

Place the thumbs below each of the client's lower eyelids is the third step. The nurse should place their thumbs below each of the client's lower eyelids, which places the nurses' thumbs in the best position for the next step.

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.

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 I

FLAG

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?

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Edema around the ear

INCORRECT

Edema around the client's ear can indicate that the client has an ear infection.

Watery, clear drainage

~ CORRECT

My Answer

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.

Yellow drainage

INCORRECT

Yellow drainage from the client's ear can indicate that the client has an ear infection.

Crusted skin

INCORRECT

Crusted skin around the client's ear can indicate that the client has an ear infection.

A nurse is preparing to palpate a clent's sinuses. laentity the sequence the nurse snoula tollow when taking the ronowing actions.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

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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.

~ CORRECT

My Answer

Position the thumbs on the supra orbital 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 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 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.

Ask 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 indicates pain the nurse would question the client about the quality, location, symmetry of the pain and document.

Position 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.

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 indicates pain the nurse would question the client about the quality, location, and symmetry of the pain and document the findings.

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

INCORRECT

A beefy red tongue can be an indication that the client has a vitamin B12 deficiency.

Swollen lymph nodes

INCORRECT

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

Lump on the anterior portion of their neck

~ CORRECT

My Answer

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

Lip color is darker than surrounding skin

INCORRECT

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.

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• A lesion on the client's scalp

Edema around the client's eyes

Oval white patches in the client's hair

_ Protrusion of the client's mastoid bone

Protrusions on the client's head

CORRECT

My Answer

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 human capitis.

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.

Protrusions on the client's head is correct. The nurse should identify that protrusions on 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.

Protrusion of the client's mastoid bone is incorrect. 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?

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Yellowing of the hard palate

INCORRECT

Yellowing of the client's hard palate can indicate a liver disorder and is an unexpected finding.

Red spots on the hard palate

INCORRECT

Red spots, or petechiae, on the client's hard palate can indicate an infection and is an unexpected finding.

White patches on the tongue

INCORRECT

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

Large vein on the ventral surface of the tongue

• CORRECT

My Answer

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

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?

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Tinnitus

• CORRECT

My Answer

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

Strabismus

INCORRECT

The nurse should document that the client is experiencing tinnitus. Tinnitus is a high-pitched ringing in the ears. Strabismus is a misalignment of the axes of the eyes.

Bell's palsy

INCORRECT

The nurse should document that the client is experiencing tinnitus. Tinnitus is a high-pitched ringing in the ears. Bell's palsy is weakness of the facial muscles causing asymmetry of facial features.

Hirsutism

INCORRECT

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.

A nurse is obtaining a client's health history. Which of the following questions should the nurse ask the client in order to obtain a focused health history of the ears?

Select all that apply.

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"Do you have ringing in your ears?"

_ "Do you have problems with nasal drainage?"

"Do you ever lose your balance?"

• "Have you ever used hearing aids?"

"Have you had trouble hearing?"

1 CORRECT

My Answer

"Have you had trouble hearing?" is correct. The nurse should ask the client about difficulties hearing when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. Asking the client about their hearing is an appropriate question for the nurse to ask for a focused ear history.

"Do you ever lose your balance?" is correct. The nurse should ask the client if they ever lose their balance when obtaining a focused health history of the ears. The function of the ears is hearing and equilibrium. Loss of balance could indicate 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 health history of the ears. The function of the ears is hearing and equilibrium. The use of hearing aids is important for the nurse to know and document as part of the focused ear history.

"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 health history of the ears. The function of the ears is hearing and equilibrium. Ringing in the ears, or tinnitus, could indicate an inner ear disturbance.

"Do you have problems with nasal drainage?" is incorrect. The nurse should ask the client if they are having problems with nasal drainage when obtaining a focused health history of the nose.

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

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Pale mucosa

• CORRECT

My Answer

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

Bright red mucosal

INCORRECT

Bright red mucosa is an indication that the client has an upper respiratory infection.

Green discharge

INCORRECT

Green discharge is an indication that the client has an infection of the sinuses.

Yellow discharge

INCORRECT

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?

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Outer layer of the eyeball

INCORRECT

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

Mucous membrane that lines the eyeball

INCORRECT

The mucous membrane that lines the eyeball is the conjunctiva.

Transparent layer that covers the iris and pupil

~ CORRECT

My Answer

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

Colored portion in the center of the eye

INCORRECT

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?

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Vital signs

INCORRECT

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

Review of systems

~ CORRECT

My Answer

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.

Allergies and home medications

INCORRECT

The nurse should document the client's home medications and newly prescribed medications from their provider in this section of the client's EHR, as well as allergies.

Patient information

INCORRECT

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.

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

Select all that apply.

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/ Assess orientation

Assess muscle strength

• Make the client NPO

_ Assess for strabismus

• Obtain vital signs

• CORRECT

My Answer

Make the client NPO is correct. 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.

Assess orientation is correct. 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.

Assess for strabismus is incorrect. 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.

Assess muscle strength is correct. 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.

Obtain vital signs is correct. 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.

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

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Ptosis of an eyelid

INCORRECT

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.

Yellow sclera

• CORRECT

My Answer

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

Edema of the eyelids

INCORRECT

Edema of the eyelids can indicate heart failure.

Reddened conjunctiva

INCORRECT

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

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.

INCORRECT

The nurse should keep the bedside table close to the client's bed or chair. It should be within arm's reach to prevent overreaching, which can place the client at risk for a fall.

Place a towel on the client's bathroom floor.

INCORRECT

The nurse should ensure the client's room is free from clutter, which decreases the risk of the client tripping or falling.

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

INCORRECT

The nurse should raise two to three side rails of the client's bed. Raising all four side rails is a restraint and can be a safety risk to the client.

Keep the client's bed in the lowest position.

• CORRECT

My Answer

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.

A nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse implement? Select all that apply (3)

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(Select All that Apply.)

Assess for facial droopiness

• Assess for tracheal deviation

Assess swallowing reflex

Assess awareness and orientation

_ Assess for Bell's Palsy

The nurse is performing an eye assessment and the client notes these changes in a client with Cataracts trouble driving at night

peripheral vision loss

* and may be caused by age related

A nurse is assessing a patient's cranial nerves. To evaluate cranial nerve IIl oculomotor, which of the following actions should the nurse ask the patient to perform?

• Ask the client to identify how many fingers the nurse is holding up

• Smile and puff out the cheeks
  Follow the nurse's finger with the eyes.
  ask the client to raise their eyebrows

The nurse is performing a head and neck assessment. The nurse uses the cover and uncover and notes asymmetry of the eye muscles. How should the nurse document this finding?

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Tinnitus

Bell's Palsy

Hirsuitism

• Stabismus

A patient presents with headache, facial pain, and tenderness under the eye area upon sinus palpation. These findings are most suggestive of involvement of which sinus?

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• Sphenoid sinus

• Ethmoid sinus

• Maxillary sinus
  Frontal sinus

The nurse assesses a client's vision to be 20/40. The client asks for an explanation of the vision results. What is the nurses best response?

• "You see better than someone with 20/20 vision"

• "You are considered legally blind"

• "You see at 20 feet what a person with normal vision sees at 40 feet, and need glasses to drive

• "You see at 40 feet what a person with normal vision sees at 20 feet"

A nurse is preparing to assess the eyes of a elderly client. Which of the following findings should the nurse expect?

cataracts

Reddened conjunctiva

stabismus

Yellow sclera

The nurse is inspecting the nasal passageway of a client who has an upper respiratory infection. Which of the following findings should the nurse expect?

• Clear nasal discharge

• pale green nasal drainage

• Pale, pink nasal mucosa

• Absence of tenderness upon sinus palpation

/Candidiasis (thrush) in adults can occur due to conditions that cause immunosuppression, steroid inhaler use, HIV, infection, broad spectrum antibiotics (kill off good flora and allow yeast to proliferate), corticosteroids, leukemia, malnutrition.

Gingivitis: red, swollen, bleeding gums. Caused by poor dental hygiene or vitamin c deficiency. May occur in pregnancy and puberty because of hormonal fluctuations. Avoid anything that can worsen bleeding