Ears, Nose, Mouth, and Throat

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching?

"Avoid substances that could be irritating to your mouth." Leukoplakia is a precursor to oral cancer. The nurse would instruct the client to avoid substances that could be irritating to the mouth. The nurse would also instruct the client to eat a healthy, balance diet, including fruits and vegetables that are high in vitamin A (vitamin A deficiency is a risk factor for oral cancer). The client also needs to be instructed in avoiding excessive exposure to sunlight and ultraviolet light. Using a humidifier would be appropriate to help prevent sinusitis.

The client asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear." Placing the tuning fork on the mastoid bone is one part of the Rinne's test, which assesses the normal pathways for sound to travel to the inner ear. Equilibrium is assessed with the Romberg test. Multiple sources of assessment data are used to determine whether hearing loss is caused by degeneration of nerves in the inner ear or repeated ear infections.

The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss." The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.

In examining a client's external auditory canal with an otoscope, the nurse discovers impacted ear wax, known as cerumen. Which of the following is characteristic of cerumen? Select all that apply.

-Keeps the tympanic membrane soft -Has bacteriostatic properties -Serves as a defense against foreign bodies -Has a sticky consistency Modified sweat glands in the external ear canal secrete cerumen, a wax-like substance that keeps the tympanic membrane soft. Cerumen has bacteriostatic properties, and its sticky consistency serves as a defense against foreign bodies. The tympanic membrane, or eardrum, not cerumen, has a translucent, pearly gray appearance and serves as a partition stretched across the inner end of the auditory canal, separating it from the middle ear.

Your client is complaining of nasal stuffiness. What drugs should you ask if she is taking? (Mark all that apply.)

-Oral contraceptives -Alcohol -Guanethidine Inquire about drugs that might cause stuffiness: oral contraceptives, reserpine, guanethidine, and alcohol.

The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following?

3+ Tonsils that touch the uvula are identified as 3+. Tonsils that are visible are graded as 1+; midway between tonsillar pillars and uvula as 2+; touch each other as 4+.

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals A tophus is a hard nodule composed of uric acid crystals. A cyst on the ear would present as a fluid-filled sac. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Scarring of the tympanic membrane occurs with repeated ear infections with perforation of the tympanic membrane

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 large amount of exudate in the sinuses Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses. Normal, air-filled sinuses would not demonstrate crepitus. Obstruction of the nostril by a foreign object would prevent sniffing or blowing air through the nostrils, but would not produce crepitus. A perforated septum would also not produce crepitus.

The nurse notes a cyst on the ear of an older adult. Which assessment data is consistent with a cyst?

A sac with a membranous lining filled with fluid A cyst on the ear would present as a fluid-filled sac. A tophus is a hard nodule composed of uric acid crystals. Redness and bulging of the eardrum is characteristic of otitis media with effusion. Swelling of the external ear canal with inflammation or infection would be referred to as an edematous ear.

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test, the nurse should place the base of the tuning fork in which of the following locations?

At the center of the client's forehead During a Weber test for assessment of hearing loss, the nurse should place the tuning fork at the center of the client's forehead. Placing the base of the tuning fork at the client's mastoid process and placing the prongs of the tuning fork in front of the external auditory canal are part of the Rinne test. Placing the base of the tuning fork in front of or behind the external auditory canal is an inappropriate technique.

A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12 A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin.

The nurse is performing the assessment shown. What is the nurse assessing in this client?

Buccal mucosa Using a tongue blade and looking at the inside of the cheek is assessing buccal mucosa. This technique is not used to assess dentition, tongue alignment, or glandular function.

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

Candida albicans infection. Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (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?

Candidiasis Thrush or candidiasis is a yeast infection on the palate, although it may appear elsewhere in the mouth. It is characterized by thick, white plaques that are somewhat adherent to the underlying mucosa. In diphtheria, the throat is dull red, and a gray exudate is present on the uvula, pharynx, and tongue. A torus palatinus is a midline bony growth in the hard palate that is fairly common in adults. Its size and lobulation vary. The lesions of Kaposi sarcoma are deep purple. The lesions may be raised or flat.

A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?

Continue with the examination Earlobes may be free, attached, or soldered (tightly attached to adjacent skin with no apparent lobe). Most African Americans and Caucasians have free lobes, whereas most Asians have attached or soldered lobes, although any type is possible in all cultural groups. Thus, this finding is normal and does not need to be reported to the physician, followed up on with a question to the client about an ear injury, or recorded and followed up on at a later visit.

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?

Cyanotic Cyanotic lips are seen in cases of cold or hypoxia. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Pallor around the lips is a finding in clients with anemia and shock. Swelling of the lips is common in local or systemic allergic reaction.

A nurse is examining a client's nose. Which characteristics of the nasal mucosa should the nurse expect to find if the client is healthy?

Dark pink, moist, and free of discharge Dark pink, moist nasal mucosa which is free of exudate is a normal finding. The nurse should find red, swollen nasal mucosa with purulent discharge in the client diagnosed with upper respiratory tract infection. Pale pink, swollen nasal mucosa with watery exudate and bluish-gray, swollen nasal mucosa with watery exudate is found in cases of allergy.

The nurse is inspecting Wharton's ducts. The nurse would expect to find these at which location?

Either side of frenulum on floor of the mouth Wharton's ducts are located on either side of the frenulum on the floor of the mouth. The ventral surface of the tongue is the underside portion of the tongue. Stenson's ducts are located on the buccal mucosa across from the second upper molars. The uvula is located at the back of the mouth, midline of the soft palate.

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 The nurse should inspect the Wharton's ducts on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right side of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate sites to inspect for salivary ducts.

A client diagnosed with Sjogren syndrome should be given which instructions?

Eye drops and sucking on hard candy may used to relieve dryness Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness. Sjogren syndrome does not affect blood pressure. Sjogren syndrome is not contagious or sexually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness.

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

False

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?

History of allergies Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Immunizations are unlikely to relate directly to this sign. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa, hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis or other infectious processes.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead. The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.

The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?

Native Americans A bifid uvula is a common assessment finding in Native Americans.

When teaching a class of school-age children about hygiene, the nurse should include which information about the ears?

Never put anything smaller than your elbow in your ears. The nurse should reinforce proper cleaning techniques such as cleaning the bowl of the helix and never introducing anything into the external auditory canal. An elbow will not fit into an ear canal; therefore stating not to put anything smaller than an elbow into the ears, eliminates putting anything into the external ear canal. It's also a fun way to educate school age children. Cotton tipped applicators can cause complications and should not be used to clean the ears. An increased amount of earwax, not decreased, can lead to conductive hearing loss.

While inspecting the tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as which of the following?

Normal tympanic membrane The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. <wbr />A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media.

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is place in the center of the client's forehead or head for the Weber test.

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle Tophi are deposits of uric acid crystals and are generally painless; they are a common physical assessment finding in clients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in clients with otitis externa. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal. Aural tenderness or pain is not usually associated with middle ear disorders.

On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client?

Paralysis of cranial nerve X (vagus) Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A bifid or split uvula is a common finding in the Native American population. A cerebrovascular accident may cause asymmetrical or loss of movement of the uvula. Infection of the tonsils does not cause a deviation of the uvula and failure of the palate to rise.

The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which finding would the nurse interpret as being normal?

Pinkish, spongy soft palate The soft palate is expected to be pinkish, soft, spongy, and movable. A negative red glow on transillumination of the sinuses indicates that a sinus is filled with pus or fluid. Nasal mucosa that is pale pink and swollen suggests allergies. Tonsils greater than 1+ are considered abnormal.

The nurse observes a white patchy area in the pharyngeal fossa of a client. What is the nurse's best action?

Prepare client for a biopsy of the lesion. The pharyngeal fossa is the most common site of oral cancer. A whitish area is a suspicious finding and will likely be biopsied. Gargling with saline and antibiotics are not recommended. This finding does not indicate a need for a tonsillectomy. Indications for tonsillectomy are repeated tonsillitis and/or tonsil hypertrophy.

Which instructions should the nurse provide to the client taking a sublingual medication?

Put the medication underneath your tongue. The highly vascular floor of the mouth is a good location for absorption of sublingual medications. The client should be taught to place the medication under the tongue for best absorption.

Which assessment of the tongue should a nurse recognize as abnormal?

Red with loss of papillae A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B 12 or niacin. The normal tongue has visible veins on the ventral surface and is pink or pale in color and moist. A normal variation seen in the older client is a fissured, topographical map-like tongue.

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?

Redness and bulging of the eardrum Redness and bulging of the eardrum are characteristic of otitis media with effusion. Clear or bloody discharge occurs with rupture of the tympanic membrane. Dense white patches on the tympanic membrane are noted with scarring of the tympanic membrane.

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. The client's symptoms are consistent with oral candidiasis which is common in clients taking antibiotics. The tongue will become further irritated if attempts are made to completely scrape off the coating or if the mouth is rinsed with peroxide. Since this condition is commonly caused by antibiotic use, then another antibiotic for the tongue would not be prescribed.

A client with advanced presbycusis admits to the nurse that he was nearly involved in a car accident because he could not hear the siren of an ambulance that was crossing an intersection through which he was driving. The client says that he lives alone and has no one else to drive him. Which of the following diagnoses can the nurse make at this time?

Risk for Injury related to hearing impairment The nurse should recognize that this client is at risk for injury related to his hearing impairment because of his near-accident. Although the client lives alone, there is no explicit evidence that he is at risk for loneliness due to his hearing impairment. There is also no indication of impaired social interaction due to his hearing impairment. The client has not expressed a desire for a hearing aid.

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

Sit with the head erect and at the eye level of the nurse The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a Semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination & palpation of the sinuses more difficult for the examiner.v

A client is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?

Stapes Sound waves are transmitted through auditory ossicles as the vibration of the eardrum causes the malleus, the incus, and then the stapes to vibrate. As the stapes vibrates at the oval window, the sound waves are passed to the fluid in the inner ear. The umbo is the base of the malleus.

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

The client has unilateral hearing loss. Unilateral hearing loss is the major indication for Weber's test, which helps distinguish between conductive hearing and sensorineural hearing. Older age, infection, and a history of stroke are not specific indications for this test.

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. In Rinne's test, the nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

The nursing instructor is discussing the difference between sensorineural and conductive hearing loss with his class. The discussion turns to evaluation for determining what kind of hearing loss a client has. What Weber test results would indicate the presence of a sensorineural loss?

The sound is better in the ear in which he has better hearing. A client with sensorineural hearing loss hears the sound better in the ear in which he has better hearing. The Weber test assesses bone conduction of sound and is used for assessing unilateral hearing loss. A tuning fork is used. A client with normal hearing hears the sound equally in both ears or describes the sound as centered in the middle of the head. A client whose hearing loss is conductive hears the sound better in the affected ear.

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include?

Thoroughly chew small amounts of food with each mouthful. Dysphagia, difficulty swallowing, increases the risk of aspiration. Thoroughly chewing small bites of food decreases this risk and is most critical for safety. Fully raising the head of the bed prevents aspiration. Dysphagia is not associated with temporomandibular joint pain, and the client may drink during meals unless explicitly contraindicated.

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?

Torus palatinus Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple.

In performing an otoscopic examination of a client's tympanic membrane, the nurse observes through the membrane the tip of a landmark at the center of the membrane. Which of the following landmarks is this?

Umbo The malleus is the nearest auditory ossicle that can be seen through the translucent membrane and includes a handle and short process, which are closer to the edge of the membrane, and the umbo, or base, which is a center point landmark of the tympanic membrane. Pars flaccida is the top portion of the membrane, which appears to be less taut than the bottom portion. Pars tensa is the bottom of the membrane, which appears to be taut.

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem?

Use of cotton swabs inside the ear Use of cotton-tipped applicators inside the ear can cause earwax to become impacted and cause ear damage. Absence of drainage would be normal. Earplug use when swimming would be an appropriate measure to prevent swimmer's ear. A history of one ear infection would not necessarily indicate a problem. However, recurrent ear infections would.

A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?

Vitamin B12 deficiency The tongue and buccal mucosa may appear smoother and shiny from papillary atrophy and thinning of the buccal mucosa. This condition is called smooth glossy tongue and may result from deficiencies of riboflavin, folic acid, and vitamin B 12.

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

acute otitis media In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

The nurse has performed the Rinne test on an older adult client. After the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

conductive hearing loss. With conductive hearing loss, bone conduction (BC) sound is heard longer than or equally as long as air conduction (AC) sound (BC ? AC).

During examination 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 The nurse should inspect the Wharton's duct on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right sides of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate to inspect salivary ducts.

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

frenulum. The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the temporal bone. It is connected to the floor of the mouth by a fold of tissue called the frenulum.

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

maxillary sinuses. The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse.

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the

soft palate. The roof of the oral cavity is formed by the anterior hard palate and the posterior soft palate.

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead. Perform Weber's test if the client reports diminished or lost hearing in one ear. The test helps to evaluate the conduction of sound waves through bone to help distinguish between conductive hearing (sound waves transmitted by the external and middle ear) and sensorineural hearing (sound waves transmitted by the inner ear). Strike a tuning fork softly with the back of your hand and place it at the center of the client's head or forehead.