"Health Assessment: Ears, Nose, Throat, & Mouth Test 3.5 "
The nurse is doing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient?
"Are you aware of having any allergies?"
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the history would be:
"Have you noticed any dryness in your mouth?"
While obtaining a history from the mother of a 1 year old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be:
"Prolonged use of a bottle can increase the risk for tooth decay and ear infections."
The nurse is obtaining a history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." the nurse's best response would be:________
"She is just starting to salivate and hasn't learned to swallow the saliva."
During the history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response?
"Sit up with your head tilted forward and pinch your nose."
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient?
"These bumps are Fordyce's granules, which are sebaceous cysts and are not a serious condition."
Visible=
1+
Grading scale for tonsils is ___-___
1-4
Halfway between tonsillar pillars and uvula=
2+
The nurse is assessing a child's mouth and the child's mother reports that the child has not yet lost any baby teeth. How many teeth should the nurse expect to find?
20 decidual teeth in the child (compared to 32 permanent teeth in the adult)
Touching the uvula=
3+
Touching each other=
4+
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of
:dehydration
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient?
A decreased ability to identify odors
The nurse performs the Rinne test on a client and has a finding of AC 30 secs, BC 15 secs. What does this score mean?
AC refers to air conduction while BC refers to bone conduction. A normal finding would be AC lasting twice as long as BC such as AC 30 secs, BC 30 secs.
______ first sign is a clear, watery discharge, rhinorrhea, which later becomes purulent. This is accompanied by sneezing, nasal itching, stimulation of cough reflex, and inflamed mucosa, which causes nasal obstruction. Turbinates are dark red and swollen.
Acute rhinitis
_______ is the normal pathway of hearing, it is the most efficient.
Air conduction (AC)
What are the two pathways of hearing?
Air conduction and bone conduction
_______ is the lateral outside wing of the nose on either side.
Ala
________ is the most common type of rhinitis presents with rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing. Note serous edema and swelling of turbinates to fill the air space. Turbinates are usually pale (although they may appear violet), and their surface looks smooth and glistening. Common allergens are dust mite, animal dander, mold, pollen. When severe, allergic rhinitis produces disordered sleep, obstructive sleep apnea, sinusitis, and poor work performance.
Allergic Rhinitis
_______ Decrease or loss of smell occurs bilaterally with tobacco smoking, allergic rhinitis, and cocaine use. Unilateral loss of smell in the absence of nasal disease is neurogenic.
Anosmia
A client comes into the clinic complaining of pain underneath her tongue. "It hurts especially when I eat or do anything involving my tongue. I've been studying like crazy for my upcoming nursing exams and this is the last thing I need!!" The nurse inspects the oral cavity and sees a small, white, round lesion underneath the tongue. What is likely the client's problem?
Aphthous ulcers, or, canker sores which are acutely painful when they come in contact with the tongue, a toothbrush or food. They can be caused by stress, exhaustion, and oral trauma.
Which of these techniques best describes the test the nurse should use to assess the function of cranial nerve X?
Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.
During an oral assessment of a 30-year-old African-American patient, the nurse notices bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding?
Assess for other signs of insufficient oxygen supply.
A pure tone audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency. This is a battery-powered, lightweight, handheld instrument that is available in most outpatient settings. With the patient sitting, prop his or her elbow on the armrest of the chair with the hand making a gentle fist. Tell the patient, "You will hear faint tones of different pitches. Please raise your finger as soon as you hear the tone; then lower your finger as soon as you no longer hear the tone." Choose tones of random loudness in decibels on the audioscope. Each tone is on for 1.5 seconds and off for 1.5 seconds. Test each ear separately and record the results. An audiometer gives a precise quantitative measure of hearing by assessing the person's ability to hear sounds of varying frequency.
Audiometric testing
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct?
Avoid touching the nasal septum with the speculum.
A mother has brought her 8 month old baby in for a checkup. She is worried because her first child's teeth came in when the baby was only 6 months old but her 8 month old has no signs of incoming teeth. As the nurse, what would you tell the mother?
Baby teeth can erupt anywhere between 6 months of age to 2 years of age. While it was normal for the first child to have incoming teeth at 6 months, there is no need to worry about the 8 month old not yet having teeth.
________ is an alternate route of hearing. Here the bones of the skull vibrate. These vibrations are transmitted directly to the inner ear and to cranial nerve VIII.
Bone Conduction (BC)
_______ On its leading edge the superior part of the nose
Bridge
_____ to tear food like a fork.
Canine
_______ is a yellow, waxy material that lubricates and protects the ear. The wax forms a sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic membrane. It migrates out to the meatus by the movements of chewing and talking.
Cerumen
______________- Erythema, scaling, and shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection. It is often seen in edentulous persons and those with poorly fitting dentures, causing folding in of corners of mouth, which creates a warm, moist environment favoring growth of yeast.
Cheilities (a.k.a. Angular cheilitis)
______ tobacco use leads to tooth loss, coronal and root caries, and periodontal disease in older adults.Chronic tobacco use and ______ highly increase risk for oral and pharyngeal cancers.
Chronic, heavy alcohol use
State 3 conditions that decrease sense of smell?
Cigarette smoking, chronic allergies, and aging.
______ divides the two nares and is continuous inside with the nasal septum
Columella
__________ hearing loss- involves a mechanical dysfunction of the external or middle ear. It is a partial loss because the person is able to hear if the sound amplitude is increased enough to reach normal nerve elements in the inner ear. It may be caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis (decrease in mobility of the ossicles.)
Conductive hearing loss
What components of sound does the cochlea interpret? (Select all that apply.) a) Amplitude b) Decibel c) Tone d) Frequency e) Direction
Correct response: • Amplitude • Frequency Explanation: The cochlea interprets two components of sound: amplitude (volume) and frequency (pitch). The cochlea does not interpret tone, direction, or decibel. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 340.
The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response? a) "The child must wear ear plugs while flying." b) "He shouldn't fly with anyone who is immunocompromised." c) "It's safe to fly because the tubes will equalize pressure." d) "He should avoid flying for 6 months after tube placement."
Correct response: "It's safe to fly because the tubes will equalize pressure." Explanation: Pressure equalization tubes equalize pressure on either sides of the eardrum; so it's a great time to fly if one has tubes in the ears. The child should wear ear plugs to keep water out of the ears when swimming. Wearing ear plugs while flying may diminish the pressure equalization advantage of the tubes. Clients do not have to avoid flying for any period of time after tube placement. Ear tubes do not have an effect on immunocompromised clients. (less) Reference: Weber, J., and Kelley, J. Health Assessment in Nursing, 5th ed., Philadelphia: Wolters Kluwer Health, 2014, Chapter 17: Assessing Ears pg. 337.
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? a) "You have nerve damage in your ears." b) "You have a conductive hearing loss." c) "You have a high frequency hearing loss." d) "You have a unilateral hearing loss."
Correct response: "You have a conductive hearing loss." Explanation: 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) Reference: Chapter 17: Assessing Ears pp. 335-341.
The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus? a) Scarring of the tympanic membrane b) A hard nodule composed of uric acid crystals c) A sac with a membranous lining filled with fluid d) Redness and bulging of the eardrum
Correct response: A hard nodule composed of uric acid crystals Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 336.
An increased risk of falls is dangerous for any patient. What patient would be at an increased risk of falls? a) A patient with a hearing loss of 45 dB. b) A patient with acute otitis media. c) A patient with vertigo. d) A patient with damage to the VIIIth cranial nerve.
Correct response: A patient with vertigo. Explanation: Vertigo is defined as the misperception or illusion of motion either of the person or the surroundings. A patient suffering from vertigo will be at an increased risk of falls. This makes options A, B and D incorrect. (less) Reference: Chapter 17: Assessing Ears, p. 331.
A mother of a small child calls the clinic and asks to schedule an appointment for ear tube removal. The call is transferred to the nurse. What is the nurse's best action? a) Ask the mother how long the tubes have been in place. b) Schedule appointment at hospital for tubes to be removed surgically. c) Ask healthcare provider about prescribing antibiotics before removal. d) Schedule first available office appointment.
Correct response: Ask the mother how long the tubes have been in place. Explanation: Ear tubes generally fall out spontaneously in 2-5 years after placement, and the membrane most often closes. The client does not need manual removal in the office or operating room unless the child is experiencing problems. Antibiotics are indicated for infection and are not necessary for removal. (less) Reference: Chapter 17: Assessing Ears pg. 337.
A nurse performs an inspection and palpation of the auricle when examining the ear of a client. Which documentation by the nurse demonstrates a normal finding? a) Darwin's tubercle b) Pale blue coloration c) Ulcerated, crusted nodules d) Nontender, hard tophi
Correct response: Darwin's tubercle Explanation: The nurse should document Darwin's tubercle as a normal finding upon examination of the auricle. Darwin's tubercle is a clinically insignificant projection seen on the auricle. Nontender, hard tophi are manifestations of gout. Ulcerated, crusted nodules can be a sign of skin cancer. Pale blue coloration of the auricle could be due to frostbite. (less) Reference: Chapter 17: Assessing Ears, p. 336.
A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube? a) Sends sensory information to the cerebellum and midbrain. b) Separates the external from the middle ear. c) Transmits vibration to the fluid filled inner ear at the oval window. d) Equalizes the pressure in the middle ear with atmospheric pressure.
Correct response: Equalizes the pressure in the middle ear with atmospheric pressure. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 328.
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? a) Eustachian tube b) The malleus c) The pinna d) The meatus
Correct response: Eustachian tube Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 328.
A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. Which of the following is a characteristic of this condition? a) Fluid collects in the middle ear causing an obstruction of the auditory tube. b) An upper respiratory infection spreads through the auditory tube. c) This condition is usually associated with a puncture eardrum. d) This condition develops if acute purulent otitis media is not treated promptly.
Correct response: Fluid collects in the middle ear causing an obstruction of the auditory tube. Explanation: Serous otitis media results from fluid that collects in the middle ear, causing an obstruction of the auditory tube. This condition may stem from infection, allergy, tumors, or sudden changes in altitude. Symptoms include crackling sensations and fullness in the ear, with some hearing loss. Acute purulent otitis media is generally caused by an upper respiratory infection spreading through the auditory tube. Pus forms and collects in the middle ear to create pressure on the eardrum. Chronic otitis media can develop if acute purulent otitis media is not treated promptly. Chronic purulent otitis media is usually associated with a punctured eardrum or may be a complication of acute otitis media, mastoiditis, or a severe upper respiratory infection. (less) Reference: Chapter 17: Assessing Ears, p. 331.
A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear? a) Yellowish-white b) Red c) Gray d) Bluish-white
Correct response: Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. This makes options A, B and D incorrect. (less) Reference: Chapter 17: Assessing Ears, p. 337.
When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify? a) Pars tensa, pars flaccida, vestibule, cone of light b) Cone of light, incus, umbo, cochlea c) Handle of malleus, short process of malleus, cone of light d) Pars tensa, umbo, handle of malleus, ossicles
Correct response: Handle of malleus, short process of malleus, cone of light Explanation: Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
The nurse is documenting an objective assessment of the client's ears. Which of the following would be the most appropriate documentation? a) Hearing intact bilaterally on whisper test b) Hearing intact on right and left with Rinne test c) No decrease in hearing evident on Weber test d) Client states experiencing no decrease in hearing
Correct response: Hearing intact bilaterally on whisper test Explanation: Documentation of the whisper test should be "hearing intact bilaterally on whisper test." Documentation of the Rinne and Weber test results usually validates normal findings (e.g., "No unexpected findings on Weber and Rinne tests."). The report from the client is a subjective assessment finding. (less) Reference: Chapter 17: Assessing Ears, p. 338.
The client is having a Weber test. During a Weber test, where should the tuning fork be placed? a) Near the external meatus of each ear. b) On the mastoid process behind the ear. c) Under the bridge of the nose. d) In the midline of the client's skull or in the center of the forehead.
Correct response: In the midline of the client's skull or in the center of the forehead. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 338.
Which precaution should a nurse take to ensure the safety of a client when performing the Romberg test? a) Place arms around the client without touching b) Offer assistance by holding the client's arm c) Tell the client to keep the eyes open & focused ahead d) Instruct the client to hold on to a chair
Correct response: Place arms around the client without touching Explanation: During the Romberg test, the nurse should put his or her arms around the client without touching to prevent the client from falling. The eyes are closed to assess the client's ability to maintain equilibrium without looking or holding onto something. The client should not be instructed to hold on to a chair during the test as it may interfere with the assessment of equilibrium. The nurse should not hold the client's arm as it would give support to the client and affect the result. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 314.
Which terms refers to the progressive hearing loss associated with aging? a) Otalgia b) Presbycusis c) Sensorineural hearing loss d) Exostoses
Correct response: Presbycusis Explanation: Both middle and inner ear age-related changes result in hearing loss. Exostoses refers to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII. (less) Reference: Chapter 17: Assessing Ears, p. 330.
What action should the nurse implement using an otoscope when assessing the ear of an adult client? a) Choose the smallest speculum for client comfort b) Insert the speculum gently down and backward c) Pull the auricle out, up, and back d) Hold the speculum in the nondominant hand
Correct response: Pull the auricle out, up, and back Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits comfortably into the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward. (less) Reference: Chapter 17: Assessing Ears, p. 335.
What action should the nurse implement when assessing the ear of an adult client using an otoscope? a) Insert the speculum gently down and backward. b) Choose the smallest speculum for client comfort. c) Pull the auricle out, up, and back. d) Hold the speculum in the non-dominant hand.
Correct response: Pull the auricle out, up, and back. Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with otitis media? a) Pearly, translucent with no bulging b) Red, bulging with an absent light reflex c) Yellowish, bulging with fluid bubbles d) Gray, translucent with retraction
Correct response: Red, bulging with an absent light reflex Explanation: 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 retraction is a normal finding in the tympanic membrane. (less) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 337.
Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? a) Yellowish, bulging, with fluid bubbles b) Pearly, translucent, with no bulging c) Gray, translucent, with no retraction d) Red, bulging, with an absent light reflex
Correct response: Red, bulging, with an absent light reflex Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 337.
A client admitted to the health care facility is diagnosed with vertigo. Which test is appropriate for the nurse to perform to assess for equilibrium in the client? a) Whisper b) Romberg c) Rinne d) Weber
Correct response: Romberg Explanation: The nurse should perform the Romberg test to assess equilibrium in the client. The Weber test and the Rinne test are used to distinguish between sensorineural and conductive hearing loss. The whisper test is used to assess hearing loss in a client. (less) Reference: Chapter 17: Assessing Ears, p. 340.
A client presents at the clinic complaining of a loss of balance. What test should the nurse expect the physician to carry out on a client with a loss of balance? a) Rinne test b) Audiometric test c) Weber test d) Romberg test
Correct response: Romberg test Explanation: The Romberg test is used to evaluate a person's ability to sustain balance. The Audiometric test measures the hearing acuity precisely, while the Rinne test and the Weber test identify the types of hearing loss (less)
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? a) Tinnitus and sensorineural hearing loss b) Impaired facial movement c) Reduced urinary output d) Signs of hypotension
Correct response: Tinnitus and sensorineural hearing loss Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 334.
When planning care for a patient with an inner ear infection, the nurse will include interventions to address which potential problem? a) Fever b) Vertigo c) Headache d) Rhinorrhea
Correct response: Vertigo Explanation: 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) Reference: Weber, J., & Kelley, J. H. (2014). Health Assessment in Nursing, 5th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, Chapter 17: Assessing Ears, p. 331.
Question: When performing a Rinne test, the nurse would perform the steps in what order? 1. place the tuning fork in front of the ear and ask the patient if she can hear the sound 2. place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound
Correct response: place the base of a vibrating tuning fork on the mastoid bone until the patient says she cannot hear the sound place the tuning fork in front of the ear and ask the patient if she can hear the sound Reference: Chapter 17: Assessing Ears, p. 339.
_________- Progressive destruction of tooth. Decay initially looks chalky white. Later it turns brown or black and forms a cavity. Early decay is apparent only on x-ray image. Susceptible sites are tooth surfaces where food debris, bacterial plaque, and saliva collect.
Dental caries
Incisor Canine First molars Second molar Are all what?
Different types of teeth
A patient who is pregnant comes into the clinic due to chronic nosebleeds. The patient states that she never had nosebleeds before the pregnancy and is worried something is wrong with the baby. As the nurse, what would you tell this patient?
During pregnancy the body has increased blood flow (hyperemia) which can cause anything from snoring to bleeding gums to nosebleeds (epistaxis). The nosebleeds do not indicate any problems with the baby, but should cease after the baby is born.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Dysphagia
collecting/transporting sound vibrations to the brain and maintaining the sense of equilibrium are the main functions of the ______.
Ear
Bridge- Nares- Columella Ala- All make up the _____________
External Structures
_________ is called the auricle or pinna and consists of movable cartilage and skin. Its characteristic shape serves to funnel sounds waves into its opening
External ear
__________—Purulent, sanguineous, or watery discharge.Acute with perforation—Purulent discharge.
External otitis
The primary purpose of the ciliated mucous membrane in the nose is to:________
Filter out dust and bacteria
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation?
Firm pressure
_____ can grind food.
First molars
Wharton's duct runs up and forward to the floor of the mouth and opens at either side of the _______.
Frenulum
______ is a midline fold of tissue that connects the tongue to the floor of the mouth
Frenulum
______ are pockets of space located above the orbit of each eye in the frontal bone. They are lined with mucus membrane, which secretes fluid that moistens and protects the areas it covers. The size and shape of the frontal sinus can vary from person to person. These spaces fill up with mucus, which then drain into the nose.
Frontal Sinus
What are the two paranasal sinuses accessible to physical examination?
Frontal and Maxillary
Functions of the _________ consist of (1) it conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear; (2) it protects the inner ear by reducing the amplitude of loud sounds; and (3) its eustachian tube allows equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture (e.g., during altitude changes in an airplane).
Functions of the middle ear
Life Span Consideration of: _______ Presbycusis Onset usually occurs in 50s Sensorineural hearing loss Unable to hear high tone loss
Geriatrics
Life Span Considerations of: ______ Otosclerosis Conductive hearing loss in young adults between 20-40 ¨Due to hardening that causes foot plate of stapes to become fixed in oval widow
Geriatrics
Life Span Considerations of: _________ Genetics Cerumen - genetically determined and comes in two major types Dry cerumen: gray, flaky, and frequently forms thin mass in ear canal Asians and American Indians have an 84% frequency of dry cerumen Wet cerumen: honey brown to dark brown and moist Blacks have a 99% and whites have a 97% frequency of wet cerumen
Geriatrics
Life span considerations for: ______ - Nasal hairs stiffer and less able to filter - Smell sensation decreases ( less nerve fibers) - Loss of taste buds - Mucous membranes atrophy- greater chance of ulcerations - Changes in teeth
Geriatrics
A pregnant client comes in for a checkup and is complaining of sore gums that appear to have become enlarged. She is worried about her symptoms, what should the nurse tell her?
Gingival hyperplasia is a condition that causes the gums to become enlarged and it is a common condition seen in pregnancy but it should dissipate after the pregnancy.
____________- Gum margins are red and swollen and bleed easily. This case is severe; gingival tissue has desquamated, exposing roots of teeth. Inflammation is usually caused by poor dental hygiene or vitamin C deficiency. The condition may occur in pregnancy and puberty because of changing hormonal balance.
Gingivities
Cranial nerve IX=
Glossopharyngeal
_______ (gingivae) collar the teeth. They are thick, fibrous tissues covered with mucous membrane. They are different from the rest of the oral mucosa because of their pale pink color and stippled surface
Gums
_______ is made up of bone and is a whitish color that is used for feeding and speech
Hard palate
Cranial nerve XII =
Hypoglossal
____ to cut food like a pair of scissors.
Incisor
_______ is embedded in bone. It contains the bony labyrinth, which holds the sensory organs for equilibrium and hearing. Within the bony labyrinth, the vestibule and the semicircular canals compose the vestibular apparatus, and the cochlea (Latin for "snail shell") contains the central hearing apparatus. Although it is not accessible to direct examination, you can assess its functions.
Inner ear
_________ is the most common site of a nosebleed
Kiesselbach plexus
______ are fleshy folds of tissue around the opening of the mouth - covered with skin on the outside and a mucous membrane on the inside. They are used for eating functions, like holding food or to get it in the mouth. In addition, they serve to close the mouth airtight shut, to hold food and drink inside, and to keep out unwanted objects
Lips
The________ is the largest of the paranasal sinuses. They are located below the cheeks, above the teeth and on the sides of the nose. They are shaped like a pyramid and each contain three cavities, which point sideways, inwards, and downwards. They reduce skull weight, produce mucus, and affect the tone quality of a person's voice.
Maxillary Sinus
______ is underlying each turbinate is a cleft, which is named for the turbinate above. The sinuses drain into the middle ______ , and tears from the nasolacrimal duct drain into the inferior ____
Meatus
________ is a tiny air-filled cavity inside the temporal bone. It contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes. It has several openings covered by the tympanic membrane.
Middle ear
______ is the oval openings at the base of the triangle; just inside, each one widens into the vestibule.
Nares
Septum, turbinates, meatus, and Kiesselbach plexus all make up the __________
Nasal Cavity
the upper part of the pharynx, connecting with the nasal cavity above the soft palate
Nasopharynx
filtration, moistening and warming of incoming air, providing an airway for respiration, providing resonance for the voice and housing the olfactory receptors. These are the functions of the _____ and __________.
Nose and paranasal sinuses
In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings?
Nothing, because this is the appearance of normal tonsils.
_________: (hair cells) lie at the roof of the nasal cavity and in the upper one third of the septum. These receptors for smell merge into the ________, which transmits to the temporal lobe of the brain. Although it is not necessary for human survival, the sense of smell adds to nutrition by enhancing the pleasure and taste of food.
Olfactory receptors, CN 1 Olfactory
Physical Appearanace of ______ : white, cheesy, curdlike patch on buccal mucosa due to superficial fungal infection.
Oral Candidiasis- (Moniliasis)
_______ is the middle part of the pharynx (throat) behind the mouth. It includes the following: Back one-third of the tongue. Soft palate. Side and back walls of the throat.
Oropharynx
______ may be caused directly by ear disease or may be referred pain from a problem in teeth or oropharynx.
Otalgia
___________(middle ear infection), occurs because of obstruction of the eustachian tube or passage of nasopharyngeal secretions into the middle ear. This creates a ripe environment for bacteria to grow. It is so common in childhood that 90% of all children younger than 2 years of age have had at least one episode. The incidence and severity are increased in indigenous children from North America, Australia, New Zealand, and Northern Europe, although genetic factors have not been determined. Rather, the most important cause is environmental; children in high-risk groups usually have multiple pathogens, and the total bacterial load is high.
Otitis Media (OM)
________ infected canal or perforated eardrum
Otorrhea
_______ is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. It is a gradual bone formation that causes the footplate of the stapes to become fixed in the oval window, impeding the transmission of sound and causing progressive deafness.
Otosclerosis
________ salivary glands are in the cheeks over the mandible, anterior to and below the ear. They are the largest of the salivary glands but are not normally palpable.
Parotid Gland
What are the two salivary glands accessible to physical exam? including their location and the location of their duct openings (e.g. Stenson's and Wharton's ducts).
Parotid gland and Submandibular
Life Span Considerations of: ______ Hearing Acuity Test Attending school
Pediatrics
Life Span consideration of: ________ Otitis media - obstruction of eustachian tube or passage of nasopharyngeal secretions into middle ear is one of most common illnesses of....
Pediatrics
Life Span considerations of: _______ Eustachian tube is relatively shorter and wider and more horizontal than adult's, so it is easier for pathogens from nasopharynx to migrate through to middle ear
Pediatrics
Life span considerations for: ________ - Salivation begins around 3 months (not related to teeth) - Deciduous teeth → lost at 6-12 years old
Pediatrics
________ occurs year-round and can result from sensitivity to pet hair, mold on wallpaper, houseplants, carpeting, and upholstery. Some studies suggest that air pollution such as automobile engine emissions can aggravate it. Although bacteria is not the cause of it, one medical study found a significant number of the bacteria Staphylococcus aureus in the nasal passages of patients with year-round allergic rhinitis, concluding that the allergic condition may lead to higher bacterial levels, thereby creating a condition that worsens the allergies.
Perennial allergic rhinitis
The nurse is assessing a 3 year old for "drainage from the nose." On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next?
Perform an otoscopic examination of the left nares
Describe the steps to manage epistaxis.- (noseBleeds)
Person should sit up with head tilted forward, pinch nose between thumb and forefinger for 5 to 15 minutes.
________- inflammation of the throat
Phargyngitis
The nurse is assessing the client's equilibrium with a Romberg test. The client is only able to balance with their feet placed further apart. How would the nurse document this and which cranial nerve might the client have a problem with?
Positive Romberg test, problem with the functioning of the vestibular apparatus (vestibulocochlear nerve VIII)
__________ is a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea. A mixed loss is a combination of conductive and sensorineural types in the same ear. It is a gradual onset over years, symmetric, mostly high-frequency loss, worse in noisy environments, whereas a trauma hearing loss is often sudden.
Presbycusis
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next?
Recognize this is a situation that requires immediate intervention.
______ Nasal mucosa is swollen and bright red with URI. Discharge is common with it and sinusitis, varying from watery and copious to thick, purulent, and green-yellow.
Rhinitis
_______ occurs with colds, allergies, sinus infection, trauma. The first sign is a clear, watery discharge,, which later becomes purulent. This is accompanied by sneezing, nasal itching, stimulation of cough reflex, and inflamed mucosa, which causes nasal obstruction. Turbinates are dark red and swollen.
Rhinorrhea
_____ or hayfever occurs in late summer or spring. Hypersensitivity to ragweed, not hay, is the primary cause in 75 percent of all Americans who suffer from this disorder. People with sensitivity to tree pollen have symptoms in late March or early April; an allergic reaction to mold spores occurs in October and November as a consequence of falling leaves.
Seasonal allergic rhinitis
______ larger than first molars, can grind food like first molars do.
Second molar
________ hearing loss- or perceptive loss signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex. A simple increase in amplitude may not enable the person to understand words. It may be caused by presbycusis, a gradual nerve degeneration that occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea.
Sensorineural hearing loss
The nasal cavity is divided medially into two slitlike air passages. The anterior part of the septum holds a rich vascular network, Kiesselbach plexus. In many people it is not absolutely straight and may deviate toward one passage.
Septum
The ______ are air filled cavities located in the face and around the nose. The sinuses are named according to the bone in which they are located.
Sinuses
______ Inflamed infected sinus areas following URI are most often viral in origin and do not require antibiotics. Consider bacterial infection when signs last >7-10 days. Major signs are mucopurulent drainage, nasal obstruction, facial pain or pressure, and loss of sense of smell. May also have fever, chills, malaise. Maxillary sinusitis has dull, throbbing pain in cheek and teeth and pain with palpation and when bending over. Frontal sinusitis has pain above supraorbital ridge.
Sinusitis-
A client comes into the clinic because part of there tongue appears "very shiny" and without tastebuds. What is this condition called and what might the nurse suggest to help relieve the symptoms?
Smooth tongue. The nurse could suggest an increased intake of vitamin B and iron as this condition is often due to a deficiency of these.
______ just posterior to the hard palate is an arch of muscle that is pinker in color and mobile. It is moveable, consisting of muscle fibers sheathed in mucous membrane. It is responsible for closing off the nasal passages during the act of swallowing, and also for closing off the airway. During sneezing, it protects the nasal passage by diverting a portion of the excreted substance to the mouth
Soft palate
The nurse is performing a Weber test (to evaluate hearing in a person who hears better in one ear than the other). The nurse asks the client if the sound is heard better in one ear or if it's equal. The client states that the sound is heard better in the right ear. How would the nurse document this finding?
Sound lateralizes to right ear.
Which of the following is a symptom related to vertigo? a) Fainting b) Syncope c) Loss of consciousness d) Spinning sensation
Spinning sensation. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 331.
Parotid duct also known as _______ duct opening to vestibule of the mouth occurs next to the upper second molar tooth
Stensen's duct
What 2 ducts are responsible for bringing saliva into the mouth?
Stensen's duct and Wharton's duct
The ______ is the size of a walnut. It lies beneath the mandible at the angle of the jaw.
Submandibular gland
________ glands at the floor of the mouth
Submandibular gland
What is another name for "Otitis Externa" and what are the symptoms?
Swimmer's ear, may be accompanied by itching, fever and enlarged lymph nodes
During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse?
Tell the patient this is herpes simplex 1 and will heal in 4-10 days.
A mother brings her 1 year old into the emergency room as her daughter has been crying and tugging on her ear. The daughter also has a fever. The nurse examines the ear with an otoscope and sees a bulging red eardrum with an absent light reflex. What does the nurse explain to the mother?
The child likely has otitis media which is an infection of the middle ear and is very common in children since their auditory canals are shorter, wider and more horizontal.
A client comes into the clinic who recently got over an upper respiratory infection. The client had been feeling better but now has pain in her teeth and has a very runny nose. The nurse palpates the client's maxillary and frontal sinuses and the client complains of tenderness during the assessment. What might be the source of the client's symptoms?
The client likely has sinusitis which often follows having an upper respiratory infection. It causes facial pain, inflammation and discharge.
A client comes into the clinic complaining of excessive discharge from the nose and uncontrollable sneezing and "stuffiness." During the health history the client mentions they just moved into a new apartment that was a complete mess and they'd been cleaning for days. What might be the cause of the client's symptoms?
The client might have an allergen onset of rhinitis. Rhinitis can also be acute when caused by a virus.
________ can cause peritonsillar absess, lymphadenitis or acute rheumatic fever
The complications of untreated Strep Throat
What are the only sinuses present at birth?
The maxillary and ethmoid sinuses
________ is translucent with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light
The normal tympanic membrane
________ separates the external and middle ear and is tilted obliquely to the ear canal, facing downward and somewhat forward. It is translucent with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light
The normal tympanic membrane- landmarks
Which action by the nurse is consistent with Weber's test? a) The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. b) The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the patient's ear. c) The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction. d) The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.
The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Explanation: 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) Reference: Chapter 17: Assessing Ears, p. 338.
The nurse goes to examine the tympanic membrane but can only see lots of a moist, dark brown substance. What is the nurse seeing and what should she/he do in this situation?
The nurse is seeing cerumen (ear wax) and should remove the cerumen with a cerumen spoon (if moist) or irrigating the ear with a warmed solution of mineral oil and hydrogen peroxide.
How are the paranasal sinuses named and which ones are accessible for examination?
The sinuses are named for the bones of the skull in which they are contained. The only 2 that are accessible for examination are frontal and maxillary.
While assessing the ears of an elderly patient, the nurse notices that the tympanic membrane appears quite thick and pale. The patient also seems to have lost some ability to hear high-frequency sounds. Are these findings normal or abnormal? What do they indicate?
These findings are normal in the older adult. These findings indicate that the patient likely has presbycusis - the gradual hearing loss associated with the aging process.
The nurse is doing an oral assessment on a 40-year-old African-American patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of these statements is true concerning this lesion?
This lesion is leukoedema and is common in darkly pigmented persons.
___________ - A white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily. Termed thrush in the newborn. It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people.
Thrush (a.k.a. Candidiasis or monilial infection)
______ is a "phantom sound" that originates within the person; it occurs with cerumen impaction, middle ear infection, and other ear disorders.
Tinnitus
_____ is the free corner of the nose
Tip
______ is a mass of striated muscle arranged in a crosswise pattern so it can change shape and position. It is vital for chewing and swallowing food, as well as for speech. The four common tastes are sweet, sour, bitter, and salty.
Tongue
_______ Bright red throat; swollen tonsils; white or yellow exudate on tonsils and pharynx; swollen uvula; and enlarged, tender anterior cervical and tonsillar nodes. Accompanied by severe sore throat, painful swallowing, fever >101° F of sudden onset. Bacterial infections may have absence of cough. With severe symptoms (listed above) or sore throat lasting >3-5 days, consider streptococcal infection and confirm with rapid antigen testing or throat culture. Treat positive tests with antibiotics. Untreated GAS pharyngitis may produce peritonsillar abscess, lymphadenitis, or acute rheumatic fever
Tonsillitis
________ either of two small masses of lymphoid tissue in the throat, one on each side of the root of the tongue.
Tonsils
A 10-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of these findings would be consistent with an acute infection?
Tonsils 3+/1-4+ with large white spots.
The nurse is assessing an elderly client's outer ear and notices a small white nodule on the helix of the ear. What are these nodules called and what are they a symptom of?
Tophi - symptom of gout
The lateral walls of each nasal cavity contain three parallel bony projections—the superior, middle, and inferior _________. They increase the surface area so more blood vessels and mucous membranes are available to warm, humidify, and filter the inhaled air.
Turbinates
The projections in the nasal cavity that increase the surface area are called the: _______
Turbinates
The nurse is looking into a client's ear and sees a pearly gray structure. What is the nurse seeing and is it normal?
Tympanic membrane (separates external/middle ear) and it is normally pearly gray in colour.
_____ is the free projection hanging down from the middle of the soft palate.During swallowing, the soft palate and it move superiorly to close off the nasopharynx, preventing food from entering the nasal cavity. When this process fails, the result is called nasal regurgitation
Uvula
Cranial nerve X =
Vagus
_________ is a feeling that the room spinning around or yourself spinning, a true twirling motion. Objective—Feels as if room spins. Subjective—Person feels as if he or she spins.
Vertigo
Submandibular duct also known as __________ connects the submandibular gland to the floor of the mouth
Wharton's duct
The nurse uses a penlight to transilluminate the sinuses. While transilluminating, the nurse can see a red glow. What does this finding mean?
a red glow is normal, indicates no inflammation of the sinuses.
The nurse asks the client about how they clean their ears and if they use a hearing aid. Is the nurse addressing behaviours, past health, environment or common concerns?
behaviours
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. In doing the inspection of his mouth, the nurse should inspect for:
bruising on the buccal mucosa or gums
Why are children at a greater risk for ear infections?
children have a more horizontal auditory tube than adults which allows for easier migration of organisms from infection in the throat to the middle ear
The nurses asks the client about changes in hearing, changes in sense of smell and difficulty swallowing. Is the nurse addressing behaviors, past health, environment or common concerns?
common concerns
How is the oral cavity divided?
divided into 2 parts by the teeth: - the vestibule (lips, buccal mucosa, outer surface of gums and teeth) -and the mouth (tongue, hard/soft palates, uvula and the mandibular/maxillary arch)
The nurse asks the client if they experience ear infections after swimming or being exposed to dust/smoke. Is the nurse addressing behaviours, past health, environment or common concerns?
environment (external)
A client who has recently been diagnosed with type 2 diabetes and hypertension comes into the clinic complaining of epistaxis. What is epistaxis and what might be a possible cause of the client's case?
epistaxis = nosebleeds. Can be caused by hypertension which may be the cause of this client's epistaxis. Can also be caused by trauma to the nose, rhinitis, or a blood coagulation disorder
Tastebuds are distributed throughout the tongue and are innervated by which 2 cranial nerves?
facial (VII) and glossopharyngeal
The tissue that connects the tongue to the floor of the mouth is the: _______
frenulum
The nurse asks a pregnant patient if she has experienced any humming in her ears. What condition is the nurse screening for?
hypertension associated with preeclampsia
Physical appearance of ______ : Chalky white, thick, raised patch on both sides of tongue; precancerous.
leukoplakia
The nurse performs a whisper test by standing 1-2 feet away from the client's side while they cover the ear of the corresponding side. The nurse whispers a phrase but the client is unable to repeat the phrase. What does this indicate?
may indicate loss of the ability to hear high frequency sounds
What are the 3 sections of the throat?
nasopharynx (behind the nose) oropharynx (behind the mouth) laryngopharynx (behind the larynx)
A yellowish, bulging membrane, with bubbles is seen in serous _________.
otitis media
The salivary gland that is the largest and located in the cheek in front of the ear is the: _______
parotid
The nurse asks the client if they have ever had any ear diseases (Menieres, vertigo..) or infections. Is the nurse addressing behaviours, past health, environment or common concerns?
past health history
The nurse is going to assess patency of the client's nose. What will the nurse do?
press finger on one of the client's nostril and ask the client to breathe through the opposite side. Repeat with other side.
How should the nurse position the client's ear before inspecting the auditory canal with an otoscope?
pull the pinna up, back and out.
Cranial nerve IX Glossopharyngeal controls _______
swallowing
Cranial nerve X Vagus controls _____
swallowing
Cranial nerve XII Hypoglossa controls _____
the movement of the tongue
Which fingers does the nurse use to palpate the sinuses?
thumbs
A gray, translucent membrane, with no retraction is a normal finding in the______________.
tympanic membrane
A pearly, translucent membrane, with no bulging is a normal finding in the __________.
tympanic membrane
