(PrepU) Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses

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 statements would the nurse include in the teaching?

"Avoid smoking and alcohol use." Leukoplakia is a precursor to oral cancer. The nurse would instruct the client to avoid smoking and alcohol use, because leukoplakia may be seen in clients who smoke heavily and use alcohol. The nurse would also instruct the client to eat a healthy, balanced 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 to avoid excessive exposure to sunlight and ultraviolet light. Using a humidifier would be appropriate to help prevent sinusitis.

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

4+ The nurse should document the tonsillar grading as 4+ because the tonsils are so large that they are touching one another. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are barely visible. Tonsils that touch the uvula are graded 3+.

The nurse assesses the frontal sinus where?

Above the eyes The frontal sinuses are located above the eyes. The maxillary sinuses are located above the jaw.

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?

Acute Pain The nursing diagnosis of Acute Pain can be confirmed because it meets the major defining characteristic of verbalization of sore throat. Impaired swallowing is not related to impaired neurologic or neuromuscular function. There is no criterion to confirm that this client cannot maintain health maintenance because this is an acute problem. No data exist to confirm the nursing diagnoses of Self-Care Deficit or Hopelessness.

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom?

Acute bacterial rhinosinusitis Frontal sinuses are tender to palpation in clients with acute bacterial rhinosinusitis. This finding would not occur with an eye infection, oropharyngitis, or acute otitis media.

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:

Cancers often occur. It is important to inspect the sides and undersurface of the tongue and the floor of the mouth, because these are areas where cancer most often develops.

The nurse would assess for which of the following after noting circumoral cyanosis in a client?

Changes in vital signs Circumoral cyanosis suggests anemia or shock. Therefore the nurse should look for changes in vital signs. Reddish lips are seen in clients with ketoacidosis and carbon monoxide poisoning. Swelling of the lips would suggest an allergic reaction.

A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?

Cranial nerve XII (hypoglossal) Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion. Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. A loss of taste discrimination occurs with a defect of cranial nerve VII (facial). The palate fails to rise and the uvula deviates to the side with cranial nerve X (vagus) paralysis.

The nurse notes that a client's gums are swollen and overgrown. What should the nurse include when assessing this client?

Current medications 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.

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?

Diets low in fruits and vegetables are a possible risk factor for oral cancer. Poor nutrition increases one's risk for oral cancers.

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

Difficulty swallowing Difficulty swallowing is dysphagia. Odynophagia is painful swallowing. Difficulty talking is aphasia.

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

Dysphagia Dysphagia can lead to aspiration and is the priority concern to maintain a patent airway. A weak gait can lead to falls but is not priority over airway. Right ptosis, or eyelid drooping, and facial weakness can inhibit certain facial movements but this is not a priority concern over airway.

A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?

Ensure a patent airway 4+ tonsils obstruct 75%-100% to midline in the back of the throat. Potential or actual acute airway obstruction requires immediate intervention and is priority. Antibiotics are likely prescribed, but airway is priority. The client may be dehydrated, but the tonsil abscess must be drained and airway ensured first. A throat culture may be collected, but the priority concern is ensuring a patent airway.

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 reduce periodontal disease Major risk reduction and health promotion goals in assessment of the nose, sinuses, mouth, and throat are related to various issues, including tobacco use, obstructive sleep apnea, oral health, and cancer. Health goals include reducing periodontal disease.

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 Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose. This child will not need an antibiotic, thus the nurse does not need to assess for allergies to medication. Blowing the nose may or may not dislodge the object and may cause further trauma to the nare.

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

Kiesselbach plexus The most common site of nasal bleeding is the Kiesselbach plexus on the anterior septum.

What is the common channel for the respiratory and digestive systems?

Oropharynx The oropharynx is the common channel for the respiratory and digestive systems. The frenulum is part of the tongue. The nares are part of the nose.

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 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 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 and palpation of the sinuses more difficult for the examiner.

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?

Thrush Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate.

A client reports bleeding gums after brushing their teeth. On further assessment, the nurse observes red, swollen gums but no recession of the gum lines. The nurse determines these signs and symptoms are most likely indicative of which of the following disorders?

gingivitis Signs and symptoms of gingivitis (early gum disease) include swollen, red, gums that bleed easily. Signs and symptoms of advanced gum disease (periodontitis) include recession of the gums accompanied by tooth loss. Dental pain may occur with dental caries, abscesses, or sensitive teeth.

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

position the handle of the otoscope to one side. Position the otoscope's handle to the side to improve your view of the structures. If an otoscope is unavailable, use a penlight and hold the tip of the nose slightly up. A nasal speculum with a penlight also facilitates good visualization.

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.

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

touching each other. 4+ Tonsils touch each other.