CA Ch. 18 PrepU

A client diagnosed with Sjogren syndrome should be given which instructions? Condom use can reduce the risk of transmission. Taking mucus thinning medication can relieve symptoms. Blood pressure should be checked frequently. Eye drops and sucking on hard candy may used to relieve dryness.

Eye drops and sucking on hard candy may used to relieve dryness.

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: Vestibule, nasal passages, and nasopharynx Ala nasi, vestibule, and ethmoid sinuses Ala nasi, turbinates, and nasopharynx Turbinates, ethmoid sinuses, and nasal passages

Vestibule, nasal passages, and nasopharynx

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Warm and humidify inspired air Cool and dry expired air Moisten and filter expired air Move mucus to the back of the throat

Warm and humidify inspired air

You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer? Clean the expired air Warm the expired air Clean the inspired air Warm the inspired air

Warm the inspired air

A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client? Exposure to the sun Chewing betel nuts Asthma Heavy alcohol use

asthma

You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? Alopecia Dysphagia Dyspnea Hoarseness

hoarseness

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? Cancer of the tonsils Laryngeal cancer Cancer of the pharynx Laryngeal polyps

laryngeal cancer

During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record? Fordyce granules Petechiae Leukoplakia Gingivitis

leukoplakia

An older client who wears dentures complains of having sore gums. What can the nurse instruct the client to help with this problem? Avoid excessive intake of sugary foods. Use toothpaste containing fluoride. Massage the gums every day. Have a dental examination every 2 years.

masage

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the sphenoidal sinuses. ethmoidal sinuses. maxillary sinuses. laryngeal sinuses.

maxillary sinuses

The nurse is performing the assessment shown. What is the nurse assessing in this client? Sinuses Turbinates Sense of smell Nasal septum

sinuses

e roof of the oral cavity of the mouth is formed by the anterior hard palate and the muscles. gums. teeth. soft palate.

soft palate

A client is brought to the emergency department in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process? Diabetic ketoacidosis Respiratory infection Small-bowel obstruction End-stage liver disease

Diabetic ketoacidosis

The client has experienced a stroke and has dysphagia. The nurse knows this is what? Difficulty talking Difficulty swallowing Painful swallowing Lack of gag reflex

Difficulty swallowing

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? Weak gait Right ptosis Dysphagia Facial weakness

Dysphagia

During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts? Either side of the frenulum on the floor of the mouth Posterior aspect of the tongue bilaterally Buccal mucosa across from the second upper molars Right side of the frenulum at the base of the gums

Either side of the frenulum on the floor of the mouth

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process? Tongue fissures Candidiasis Peritonsillar abscess Deviated septum

Tongue fissures

A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis? Thrush (candidiasis) Torus palatinus Leukoplakia Kaposi's sarcoma

Torus palatinus

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the tongue? Use a square gauze pad to hold the client's tongue to each side. Use a penlight and tongue depressor to retract the lips. Ask the client to stick the tongue out between the lips Put on gloves and retract the client's lips and cheeks.

Use a square gauze pad to hold the client's tongue to each side

The submandibular glands open under the tongue through openings called parasinal ducts. Wharton ducts. Stensen ducts. lacrimonasal ducts.

Wharton ducts

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? allergic rhinitis rhinitis medicamentosa epistaxis acute bacterial sinusitis

acute bacterial sinusitis

A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? Pallor Reddish Swelling Cyanotic

cyanotic

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition? Syphilis Actinic cheilitis Angioedema Herpes simplex

herpes simplex

A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client? Rinse mouth with antifungal medication as prescribed. Scrape off the white coating with a toothbrush. Apply the prescribed topical antibiotic gel as directed. Clean mouth and tongue with hydrogen peroxide and water.

inse mouth with antifungal medication as prescribed.

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? inspect the nostrils with an otoscope Assess for allergies to antibiotic Reassure the mother that this is common in children Have the child blow the nose to assess drainage

inspect the nostrils with an otoscope

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are visible upon inspection. touching the uvula. midway between the tonsillar pillars and uvula. touching each other.

touching each other.

The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client? Vitamin deficiency Cranial nerve XII damage Yeast infection Recent use of antibiotics

vitamin deficiency

A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

1+

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? 1+ 3+ 2+ 4+

3+

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? Pink, moist, firm Red, bleeding Enlarged, reddened A grey-white line

A grey-white line

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A perforated septum Obstruction of the nostril by a foreign object A large amount of exudate in the sinuses Normal, air-filled sinuses

A large amount of exudate in the sinuses

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? Ineffective Health Maintenance Hopelessness Self-Care Deficit Acute Pain

Acute pain

The Kiesselbach plexus is the most common site for what? Posterior nosebleeds Anterior nosebleeds Sinusitis Infections

Anterior nosebleeds

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? Press firmly on the back of the tongue Ask the client to stick out the tongue Depress the tongue slightly off center Ask the client to say "aaah"

Ask the client to say "aaah"

The nurse is performing the assessment shown. What is the nurse assessing in this client? Buccal mucosa Glandular function Tongue alignment Dentition

Buccal mucosa

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: Early jaundice can be detected. Cancers often occur. Sloughing of papillae begins. Lesions from loose dentures are found.

Cancers often occur.

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely Fordyce spots. leukoplakia. Koplik spots. Candida albicans infection.

Candida albicans infection.

During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding? Diphtheria Torus palatinus Kaposi sarcoma Candidiasis

Candidiasis

While a nurse is examining his sinuses, a 10-year-old boy asks the nurse what the sinuses are for. Which of the following should the nurse mention as functions of the sinuses? Select all that apply. Act as resonance chambers during speech Assist with moving food and swallowing Help break down and lubricate food Protect against infection Decrease the weight of the skull

Decrease the weight of the skull Act as resonance chambers during speech

During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client? Periodontal disease Gingival hyperplasia Significant dental caries Ill-fitting dentures

Gingival hyperplasia

When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of rhinorrhea. Which question should the nurse ask to determine associated manifestations of this symptom? "How long does it last?" "In which side does it occur? "What color is the drainage?" "Have you had a sore throat?"

Have you had a sore throat?"

A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation? How to safely put an infant to bed with a bottle How oral cancer is diagnosed Beginning dental care in children at age 5 How to reduce periodontal disease

How to reduce periodontal disease

A client comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from?

Kiesselbach plexus

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? Ala Columella Kiesselbach plexus Rosenmuller fossa

Kiesselbach plexus

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate? Stensen's duct Rosenmuller's fossa Wharton's ducts Kiesselbach's plexus

Kiesselbach's plexus

An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem? Massage the gums daily. Have a dental examination every 2 years. Avoid excessive intake of sugary foods. Use toothpaste containing fluoride.

Massage the gums daily

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? Bifid uvula Brown spots on the chewing surface of teeth Enlarged palatine tonsils Receding and ischemic gums

Receding and ischemic gums

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? Red, bleeding Enlarged, reddened A grey-white line Pink, moist, firm

Red, bleeding

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection? Bluish gray, swollen, with watery exudate Dark pink, moist, & free of discharge Pale pink, swollen, with watery exudate Red, swollen, with purulent discharge

Red, swollen, with purulent discharge

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?

Sitting with the head erect and at the eye level of the nurse

On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process? Small bowel obstruction Respiratory infection End-stage liver disease Diabetic ketoacidosis

Small bowel obstruction

Before examining the mouth of an adult client, the nurse should first

don clean gloves for the procedure.

The frontal sinuses are the only ones readily accessible to clinical examination. t or f

false

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the soft palate. mandible. gums. frenulum.

frenulum.

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? penlight tongue depressor tuning fork gloves speculum

gloves penlight tongue depresso

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect? Diphtheria Thrush Torus palatinus Kaposi's sarcoma

thrush

The rich blood supply of the nose serves to

warm the inspired air

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client? "Are you taking high blood pressure medication?" "Are you experiencing sinus pressure and congestion?' "Do you have a family history of severe headaches?" "Have you ever had an injury to your head or neck?"

"Are you experiencing sinus pressure and congestion?'

The nurse identifies this as trapping debris and propelling it toward the nasopharynx.

cilia