Health Assessment Ch. 12

Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?

Counsel HHT patients regarding lifestyle and dietary factors that may potentially decrease the occurrence of nosebleeds, such as room humidification and the use of topical nasal creams along with nasal saline treatments. Dietary recommendations including decreasing foods high in salicylates such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E (Silva et al., 2013).

The teeth are composed of what three layers? Select all that apply.

Crown Neck Root The three layers of the teeth include the crown, neck and root. The enamel and pulp are layers of the crown.

24. An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding? A) A 4-year-old girl who has all of her primary teeth B) A 20-year-old man who has type 1 diabetes mellitus C) A 39-year-old woman who has just finished a course of oral antibiotics D) A 77-year-old man who describes himself as being healthy

D) A 77-year-old man who describes himself as being healthy

6. While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding? A) Have the client provide a 24-hour diet recall. B) Review the client's medication regimen. C) Prepare the client for a thyroid screening. D) Assess the client's cranial nerve function.

D) Assess the client's cranial nerve function.

16. On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment? A) History of abuse B) Chronic nose picking C) Mucosal polyps D) Chronic allergies

D) Chronic allergies

13. While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority? A) Anterior-posterior and lateral chest x-ray B) Complete blood count with differential C) Dietitian referral D) Intravenous fluid replacement

D) Intravenous fluid replacement

27. The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussion

D) Pain on percussion

19. The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal? A) Absence of red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Pinkish, spongy soft palate

D) Pinkish, spongy soft palate

17. A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following? A) The physician will write a prescription for antibiotics. B) The drainage will need to be cultured. C) A repeat procedure will be done in 1 week to compare findings. D) The headaches are most likely not from a sinus infection.

D) The headaches are most likely not from a sinus infection.

9. A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? A) III B) VI C) VIII D) XII

D) XII

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.

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for

Dysphagia (difficulty swallowing) or odynophagia (painful swallowing) may be seen with poorly fitting dentures. Dysphagia increases the risk for aspiration, and clients with dysphagia may require consultation with a speech therapist.

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?

Enlarged, reddened The nurse may find enlarged, reddened gums in the client as an adverse effect of the phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. A grey-white line along the gum line is seen in cases of lead poisoning.

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure. The eustachian tube opens during swallowing or yawning. Its function is to equalize the pressure in the middle ear with atmospheric pressure so that there is equal pressure on both sides of the tympanic membrane to allow the drum to vibrate freely. The stapes transmits the vibration to the fluid-filled inner ear at the oval window. The vestibule sends information to the cerebellum and the midbrain. The tympanic membrane separates the external from the middle ear. (less)

The nursing student hopefuls are taking a pre-nursing anatomy and physiology class. What will they learn is the anatomical feature that equalizes air pressure in the middle ear?

Eustachian tube The eustachian tube extends from the floor of the middle ear to the pharynx and is lined with mucous membrane. It equalizes air pressure in the middle ear. Options B, C and D do not equalize pressure in the middle ear. (less)

The nurse is planning instructions for a patient with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.)

How to breathe through the mouth Importance to increase oral fluids Safety measures because of a loss of smell Remind that the voice may sound different Because the nose is the site of inspiration and expiration, the nurse will need to instruct the patient on mouth breathing. Because the nose filters, warms, and adds moisture to the air, the nurse will need to instruct the patient to increase oral fluids. Because the nose is the sensory organ for smell, the nurse will need to instruct the patient on safety measures because the nose is broken. Because the nose provides resonance to speech, the nurse will need to remind the patient that the voice may sound different because of the broken nose. The functions of the nose do not include throat soreness or effect swallowing.

During an assessment the nurse observes the client's throat as shown. Which cranial nerve should the nurse suspect is damaged in this client?

In CN X paralysis, the soft palate fails to rise and the uvula deviates to the opposite side (points "away" from the lesion). CN I is the olfactory nerve. This finding does not suggest a problem with the client's sense of small. CN VII is the facial nerve. Facial paralysis would occur if this nerve was damaged. CN IX is the hypoglossal nerve. Tongue deviation occurs when this nerve is damaged.

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. (less)

The nurse has completed a focused ear and hearing assessment and gathered the following data: the client speaks very softly, denies hearing loss, and has never had and cannot afford additional hearing tests; the client fails the whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a health promotion diagnosis of readiness for enhanced communication would be inappropriate. (less)

The following data are gathered: speaks very softly, denies hearing loss, has never had and cannot afford additional hearing tests, fails whisper test. Which nursing diagnosis would be most appropriate?

Ineffective health maintenance, related to denial of hearing problem and inadequate resources for additional testing A nursing diagnosis of ineffective health maintenance would be most appropriate based on the data. There is nothing to suggest that the client is having difficulty with social interaction. A soft-speaking voice does not indicate a problem with impaired verbal communication. The client has a problem, so a wellness diagnosis of readiness for enhanced communication would be inappropriate. (less)

A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client?

Infection with a certain type of human papillomavirus (HPV), heavy alcohol use, and smoking cigarettes are all risk factors for oropharyngeal cancer, but none of them is specifically associated with Asian culture. Chewing betel nuts, a nut containing a mild stimulant that is popular in Asia, is also a risk factor, associated specifically with this client's culture.

The nurse is performing an ear assessment of an adult client. Which of the following actions constitutes the correct procedure for using an otoscope when examining the client's ears?

Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)

Which of the following denotes the correct procedure for using an otoscope when examining the ears of a 32-year-old client?

Inserting the speculum down and forward into the ear canal The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used. (less)

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. Which of the following should the nurse assess first?

Inspect the client's external ear canal. Purulent, bloody drainage suggests external otitis, an infection of the external ear canal. Therefore the nurse would need to inspect the external auditory canal. Assessing the tympanic membrane would be appropriate if the client has purulent drainage, pain, and complained of a popping sensation, which is associated with otitis media and tympanic perforation. Palpation of the tragus is not an immediate priority in cases of suspected external otitis. Hearing assessments may later be indicated, but these would not be performed at the beginning of the assessment. (less)

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?

Laryngeal cancer Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

Laryngeal cancer Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.

An older patient who wears dentures complains of having sore gums. What can the nurse instruct the patient to help with this problem?

Massage the gums every day. Regular massage of the gums relieves soreness and pressure from dentures on the underlying soft tissue. Avoiding excessive intake of sugary foods is a strategy to reduce the risk of cariogenic bacteria. The patient with dentures will not use toothpaste but rather a cleanser specific for dentures. The patient with dentures should have a dental examination every year.

A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?

Maxillary

The nurse palpates a client's auricles and notes an elarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding. Lymph tissue should not be palpable on the ears. Enlarges lymph nodes indicate pathology or inflammation; and the healthcare provider should be notified. Ear drops are not indicated since the node is on the auricle, not in the canal. An audiogram is indicated for hearing loss. (less)

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

On the client's 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 placed in the center of the client's forehead or head for the Weber test. (less)

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. (less)

Which statement regarding oral cancer is correct? Select all that apply.

Oral cancer occurs more frequently in males. Oral sex and smoking are risk factors for oral cancer. Caucasians have a higher incidence of oral cancer. African Americans have a higher mortality related to oral cancer.

A patient comes to the clinic and reports pain when he touches his ear. With what is this finding most consistent?

Otitis externa Pain with auricle movement or tragus palpation indicates otitis externa or furuncle.

A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?

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

A 66-year-old client states that he has increasing difficulty hearing high-pitched sounds. The patient's statement most likely suggests that he has what diagnosis?

Presbycusis Presbycusis, a gradual hearing loss that often begins with a loss of the ability to hear high-frequency sounds, is common after age 50. Vertigo refers to a true spinning motion. Otalgia refers to ear pain. Tinnitus refers to ringing in the ears. (less)

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex A client with acute otitis media would have a red, bulging eardrum, with absent light reflex. A pearly, translucent membrane, with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane, with bubbles is seen in serous otitis media. A gray, translucent membrane, with no retraction is a normal finding in the tympanic membrane. (less)

An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should

Refer a client who experiences frequent nosebleeds for further evaluation.

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. Which of the following would be most appropriate?

Refer the client for further evaluation. Bone conduction greater than air conduction suggest a conductive hearing loss. When data suggest signs and symptoms requiring diagnosis and treatment, the client should be referred to a physician for further evaluation. Taking a swab for culture testing is irrelevant; infection does not cause this change in hearing function. Repeat testing is unlikely to yield differing results. (less)

A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client?

Risk factors associated with oropharyngeal cancer are as follows: using tobacco products (including cigarettes, cigars, pipes, and smokeless and chewing tobacco), heavy alcohol use, chewing betel nuts (but not high consumption of cashew nuts), infection with a certain type of human papillomavirus (not hepatitis C), being exposed to sunlight (lip cancer only, which this client shows no signs of), being male (not female), fair skin, poor oral hygiene, poor diet/nutrition, and a weakened immune system.

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should

Rough, crusty, or eroded areas are warning signs of cancer and need to be referred for further evaluation.

In which position should the nurse place the toddler when examining the ear?

Sitting on the parent's lap with parent steadying the head The toddler should sit on the parent's lap with the parent steadying the head. Preschoolers often need to be held down on the examination table in a supine position with the head turned toward the parent. Older children can sit on the examination table. (less)

The nurse is presenting an educational event for gardeners. When discussing the ears, what would be an important topic to cover?

Skin cancer prevention Many melanomas develop near or on the helix of the ear. Teaching clients how to protect themselves from unnecessary sun exposure increases the likelihood of preventative behaviors. Otalgia is an earache. Tinnitus is ringing in the ears. Sound control would be related to environmental loud noises. None of the three would be a topic for gardeners. (less)

Which of the following is a symptom related to vertigo?

Spinning sensation Vertigo is defined as the misperception or illusion of motion of the person or the surroundings. Most people with vertigo describe a spinning sensation or say they feel although objects are moving around them. (less)

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment?

Tender tragus A tender tragus is associated with otitis externa or a postauricular cyst. Darwin's tubercle is a clinically insignificant finding. Normally, cerumen may be yellow, orange, red, brown, gray, or black and soft, moist, dry, flaky, or even hard. A pearly gray tympanic membrane is a normal finding. (less)

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?

The client has a recent onset of a frontal headache and the nurse should collect information on additional findings of a sinus infection. Family history of headaches will not provide information about the current headache. High blood pressure causes a headache in the occipital area. A previous injury will not explain the recent acute onset of headache that the client is now experiencing. "Are you experiencing sinus pressure and congestion?'

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. (less)

A client has returned from outpatient surgery where a biopsy revealed a nodule on the laryngopharynx. The client asks where this is located. What is the best response by the nurse to the client about the location of laryngopharynx?

The laryngopharynx is the lowest portion of the pharynx. It extends from the epiglottis to the openings of the larynx and esophagus. The section of the pharynx that extends from the nares to the uvula is called the nasopharynx. The oropharynx is the part of the pharynx extending from the uvula to the epiglottis. The auditory (Eustachian) tubes connect the nasopharynx with the middle ear.

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 patient'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 patient's ear. (less)

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. In the Rinne test, the nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. 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. 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 patient's ear. (less)

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?

The sides of the tongue are the most common area for carcinoma to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity. The nurse should inspect all surfaces of the tongue & buccal mucosa for the presence of oral cancer.

Which glands are responsible for mouth drainage? Select all that apply.

The sublingual, parotid and submandibular glands are responsible for mouth drainage. Sebaceous glands may be located on tongue. The lacrimal duct is part of the nose.

What is the purpose of the tongue? (Select all that apply.)

The tongue manipulates solids and liquids in chewing and swallowing. It is also involved in speech production and taste. The anterior two thirds of the tongue surface contain taste buds known as vallate papillae, which identify sweet, sour, salty, and bitter tastes. The other options are distracters for the question.

A 52-year-old patient 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.

A nurse is preparing a class for a group of parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to this infection than adults. Which of the following would the nurse include?

Their eustachian tube is shorter, straighter, and narrower. The fact that children are more susceptible than adults to otitis media is due mostly to the shorter, straighter, narrower eustachian tubes of children. Otitis media in children is not associated with putting things in their ears, immature immune systems, or poor hand-washing techniques. (less)

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?

There is a sensorineural hearing impairment. With the Weber test, lateralization of sound to the good ear suggests sensorineural hearing loss because of the limited perception of sound due to nerve damage in the affected ear, making sound seem louder in the unaffected ear. Lateralization to the poor ear suggests conductive hearing loss. (less)

During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?

This is gingival hyperplasia, or an overgrowth of gum tissue. It is seen in pregnancy, puberty, leukemia, and medications such as phenytoin. Gum tissue would not be overgrown if dentures are worn. This is not periodontal disease or evidence of significant dental caries.

During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding?

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.

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity. (less)

The nurse understands that malocclusion may be related to what?

Tooth loss Malocclusion may occur with tooth loss. Rhinitis and sinusitis included infection or drainage. Parotid duct occlusion occurs in the mouth.

The nurse teaches the client that overuse of this medication can cause rebound nasal congestion.

Topical decongestants

When assessing the ears of older adults, it is necessary to remember that physiologic changes take place as people age. What is a physiologic change that takes place in the ear of an older adult?

Tympanic membrane is more opaque The cartilage and skin around the external ear may be less pliable in older adults. The stiff hairs in the canal may require a smaller otoscope tip to separate them and increase visualization of the tympanic membrane. The membrane itself may seem more opaque and less mobile. The cone of light does not become brighter as people age nor does the external ear canal enlarge. (less)

During an examination of the oral cavity, which technique by the nurse is most likely to improve visualization of the buccal mucosa?

Use a penlight and tongue depressor to retract the lips.

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.

The nurse is using audiometry to screen the hearing of elementary school students. Which best describes audiometry?

Uses headphones and a box that delivers tones to each ear at variable frequencies and volumes. Headphones and a box that delivers tones to each ear at variable frequencies and volumes are used in testing hearing by audiometry. A tuning fork, a U-shaped instrument, is used to assess sound perception through bone and air conduction. An audiologist assesses hearing with an audiogram by placing the individual in a sound-proof booth. An audiologist measures oto-acoustic emissions with a tympanogram. (less)

When providing patient education on hearing, patients should be reminded to utilize ear plugs when they are what? (Mark all that apply.)

Using lawnmowers • At train stations • At concerts As nurses, prevention is key, and patients should be reminded to utilize ear plugs when exposed to loud noises in their daily lives (e.g., lawnmowers, leaf blowers, chainsaws, concerts, train stations, battlefields, and sirens) and to limit exposure (iPod buds and cell phones). (less)

When planning care for a client with an inner ear infection, the nurse will need to include interventions for which of the following potential problems?

VERTIGO The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance. If these structures are infected or inflamed, the patient could develop vertigo. Rhinorrhea, fever, and headache are not potential problems associated with an inner ear infection. (less)

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 After entering the anterior nares, air enters the vestibule and passes through the narrow nasal passage to the nasopharynx.

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

Wearing ear protection when in the work environment An important risk prevention strategy would be to use ear protection when working or spending time in high noise levels. Even brief exposure can have harmful effects, and cleaning ears regularly would have no effect on preventing hearing loss due to environmental exposure. (less)

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

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

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the

area underneath the tongue.

Upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red, and itchy. The nurse would expect this finding with a diagnosis of

chronic otitis media

The nurse is planning to provide discharge teaching for a client with surgical repair of a septal perforation. Which points should be included to address the expected alterations in nasal function? Select all that apply.

techniques for breathing effectively through the mouth increasing oral fluid intake awareness of loss of smell anticipating short term hoarseness of the voice

A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?

"Are you experiencing any tooth pain?" Brown spots on the chewing surface on the teeth may indicate tooth decay which also may cause pain with chewing. Clients who smoke or drink large quantities of coffee or tea may have a brownish tint to the teeth. Trouble chewing would indicate missing or malocclusion of the teeth.

A 55-year-old client is being evaluated for a hearing impairment. Which question would be most appropriate to provide the most useful information?

"Are you having difficulty hearing high-frequency sounds?" Asking the client about changes in hearing ability with different frequency sounds would be most appropriate because the client is over age 50 and may be experiencing presbycusis, a loss of ability to hear high-frequency sounds. Asking about drainage would provide information about a possible infection; asking about pain would provide information about possible ear infection, cerumen blockage, sinus infections, or teeth and gum problems. Asking about a popping sensation may be appropriate if otitis media and perforation are suspected. (less)

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?" Ringing in the ears (tinnitus) may be associated with excessive ear wax buildup, high blood pressure, or certain ototoxic medications. None of the other questions pertains to conditions related to high blood pressure. Ear pain is associated with ear infections, cerumen blockage, sinus infections, teeth and gum problems, and swimmer's ear. Drainage usually indicates infection. Hearing loss may be related to any number of causes but is not associated with high blood pressure. (less)

Which question asked by the nurse is assessing problems with tinnitus?

"Do you experience buzzing in your ears?" The nurse assesses tinnitus by asking, "Do you experience buzzing in your ears?" Problems with balance occur with vertigo. Drainage from the ear(s) occurs with otalgia. The question, "In what situations is it hard for you to hear?" assesses for general hearing loss. (less)

A client reports having difficulty smelling food aromas over the past month. Which questions should the nurse include in the health history?

"Do you smoke cigarettes?' "Have you had a cold or flu recently?" "Have you had nasal surgery before?" "Are you taking any antibiotic medication?" An impaired sense of smell is common in clients who smoke cigarettes. Recent exposure to viral or bacterial infection causing respiratory symptoms is associated with an impaired sense of smell. This is resolved once the changes to the nasal mucosa normalize postinfection. Asking the client about nasal or sinus surgery provides information about any structural alterations that would impair smell. Some antibiotic medications can alter the sense of smell. Asking this question also provides clues about recent bacterial respiratory infections. Epistaxis, commonly known as the nosebleed, is not associated with a loss or impairment of smell.

A client's nasal mucosa is pale reddish-blue. What should the nurse ask the client to validate this finding?

"Do you sneeze a lot when around fresh cut grass or pollen?" In allergic rhinitis the nasal mucosa may be pale blue or red. A perforated septum is associated with inhaled substances. Thick discolored mucus or gross pus is seen with an infection. Absence of normal structures suggests previous nasal surgery.

A parent reports her preschool-aged child has been having epistaxis every 2 to 3 days for the past month. Which questions should the nurse ask to determine the possible causes? Select all that apply.

"Does your child have painless bruising?" "Does your child pick his nose?" "Is your child taking any medications?"

The patient 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. (less)

The results of a client's Rinne test are as follows: bone condcution > 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. (less)

Upon assessment of the tonsils, the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?

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?

3+

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 (less)

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. (less)

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

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.

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?

A story his wife is telling him Presbycusis often begins with a loss of high-frequency sounds (woman's voice) followed later by the loss of low-frequency sounds. The bass speakers, his son's voice, and the engine starting would all have lower-frequency sounds than his wife's voice. (less)

A mother brings her 6-month-old child to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the client's mouth?

A white coating of the tongue may be oral candidiasis. This condition is very common in clients taking antibiotics. Red and white patches in the throat might indicate strep throat, which would be an unexpected finding. A white uvula and white patches on the buccal mucosa are distracters for this question.

7. A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition? A) Crepitus over the maxillary sinuses B) Frontal sinuses nontender to palpation C) Red, tender tympanic membrane D) Increased amounts of saliva production

A) Crepitus over the maxillary sinuses

11. The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask? A) Have you lost any teeth recently? B) How would you describe your typical diet? C) Has your dentist screened you for oral cancer recently? D) Are you able to taste the food you eat?

A) Have you lost any teeth recently?

3. 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? A) History of allergies B) Incomplete immunization record C) History of epistaxis (nosebleeds) D) Prolonged tonsillar enlargement

A) History of allergies

22. The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? A) How often do you use over-the-counter nasal sprays? B) How often do you take Tylenol? C) How many drinks of alcohol do you have in a typical day? D) Would you say that you eat a balanced diet?

A) How often do you use over-the-counter nasal sprays?

18. A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply. A) Salts B) Proteins C) Fats D) Mucus E) Amylase

A) Salts D) Mucus E) Amylase

29. A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance? A) Thick, white plaques on the tongue surface B) Dry appearance with fissures present C) Diffuse reddened lesions that bleed easily D) Firm, raised nodules that are pink or red

A) Thick, white plaques on the tongue surface

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding?

Acute otitis media A red, bulging eardrum coupled with distorted, diminished, or absent light reflex is associated with acute otitis media. Repeated ear infections usually cause the formation of white scar tissue. Trauma causes the accumulation of blood behind the eardrum, which appears blue or dark red. (less)

Audiometry is testing that measures hearing acuity precisely. Who does the nurse know can perform audiometric testing?

Audiologist Audiometry is done by an audiologist. Audiometric testing measures hearing acuity precisely. Options A, B and D can screen hearing but they cannot do audiometric testing.

23. The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies. How can the nurse begin to identify the specific allergens that cause the man's symptoms? A) Ask the client if his allergies respond to OTC antihistamines. B) Ask the client about the timing of his allergy symptoms. C) Perform a detailed inspection of the client's ears and throat using an otoscope. D) Perform transillumination of the client's sinuses.

B) Ask the client about the timing of his allergy symptoms.

10. When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding? A) Enlarged pharyngeal tonsils B) Enlarged palatine tonsils C) Enlarged adenoids D) Enlarged lingual tonsils

B) Enlarged palatine tonsils

1. The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up? A) Thrush B) Leukoplakia C) Gingivitis D) Canker sore

B) Leukoplakia

15. 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? A) Italian Americans B) Native Americans C) African Americans D) Non-Hispanic Americans

B) Native Americans

26. A client has presented with a terrible head cold, and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply. A) Inspection B) Palpation C) Auscultation D) Percussion E) Transillumination

B) Palpation D) Percussion E) Transillumination

14. The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next? A) Facilitate blood testing for human immunodeficiency virus (HIV). B) Refer the client to a primary care provider for medication. C) Asses the client's laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.

B) Refer the client to a primary care provider for medication.

5. When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority? A) Determining whether the client is receiving phenytoin therapy B) Referring the client for further evaluation C) Encouraging the client to enroll in a smoking cessation program D) Providing the client with information on proper mouth care

B) Referring the client for further evaluation

30. The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say aaah. This finding should prompt the nurse to focus on which of the following during subsequent assessment? A) The client's nutritional status B) The client's neurological status C) The client's immune function D) The client's respiratory function

B) The client's neurological status

A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect?

Both sides

8. The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following? A) 1+ B) 2+ C) 3+ D) 4+

C) 3+

20. When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum line

C) Area under the tongue

12. During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess? A) Asking if the client experiences dry mouth often B) Inspecting for inflammation of the tonsils C) Checking for a deviated nasal septum D) Performing a focused respiratory assessment

C) Checking for a deviated nasal septum

21. A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A) Would you say that you're prone to getting mouth ulcers? B) Do you brush and floss daily? C) Do you use tobacco, whether smoking or chewing? D) How often do you usually go to the dentist in a year?

C) Do you use tobacco, whether smoking or chewing?

2. In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client? A) Decreased sense of taste B) Difficulty hearing C) Impaired sense of smell D) Occasional dizziness

C) Impaired sense of smell

25. Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding? A) Swab the lesion to obtain a sample for culture and sensitivity testing. B) Recommend that the client gargle with saltwater twice daily for several days. C) Refer the client to her primary care provider promptly. D) Determine whether the lesion can be removed with a sterile cotton-tipped applicator.

C) Refer the client to her primary care provider promptly.

28. The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? A) Risk for injury related to potential esophageal trauma B) Risk for oral infection related to dysphagia C) Risk for aspiration related to decreased swallowing ability D) Risk for excess fluid volume related to decreased peristalsis

C) Risk for aspiration related to decreased swallowing ability

4. The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include? A) Sit with the head of the bed at 45 degrees during meals. B) Be aware of the possibility of temporomandibular joint pain. C) Thoroughly chew small amounts of food with each mouthful. D) Drink fluids before and after, but not during, meals.

C) Thoroughly chew small amounts of food with each mouthful.

After having a client perform a Romberg test, which of the following would indicate to the nurse that the test is negative?

Client maintains the position during the exam A negative Romberg test is documented when the client maintains position for 20 seconds without swaying or with minimal swaying. The test is positive if the client moves the feet apart to prevent falls, or starts to fall from loss of balance. (less)