Health Assessment PrepU Ch. 12 (Ears, Nose, Mouth, and Throat)

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

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

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

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

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

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

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

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

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

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

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

False

During examination of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

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

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the

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

The nurse notes thrush on the palate of a client. The most appropriate question the nurse should ask is

"Have you been on antibiotics recently?"

A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data?

"Are you having difficulty hearing high-frequency sounds?" Explanation: Asking the client about changes in hearing ability with different frequency sounds would be most appropriate. This is 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.

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?

"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.

A client has sought care at the clinic, telling the nurse, "This ringing in my ears has gone on for weeks, and it's driving me crazy." The client denies exposure to excessive noise levels. What would the nurse ask next?

"What medications are you currently taking?" Explanation: Tinnitus may be associated with certain ototoxic medications. There is not usually a family history of this problem. Cerumen buildup can contribute, but hygiene is not a common etiology of tinnitus. The client's overall perception of health is important but is less likely to explain why he is experiencing tinnitus.

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

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

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

A hard nodule composed of uric acid crystals 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

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?

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

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

A sac with a membranous lining filled with fluid Explanation: 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.

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

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

The Kiesselbach plexus is the most common site for what?

Anterior nosebleeds Explanation: The Kiesselbach plexus is the most common site for anterior nosebleeds.

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?

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.

A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?

Asthma Explanation: This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke. The other answers listed—chewing betel nuts, exposure to the sun, and heavy alcohol use—are all risk factors for oropharyngeal cancer, but not for sinusitis.

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

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

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

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

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

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

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

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

During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?

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

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

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

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

Grinding Explanation: The molars are responsible for grinding and final chewing before swallowing. The incisors are responsible for biting food.

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear Explanation: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options do not accurately describe the function of the eustachian tube.

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

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

When providing client teaching about the ears, what should the nurse be sure to include?

How the client cleans the ears Explanation: It is important to address how the client cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, clients think that cotton-tipped applicators are for this purpose. This self-care behavior is unsafe, placing clients at risk for cerumen impaction. Nurses should reinforce proper cleaning techniques. Since cleaning with cotton-tipped applicators is not correct, the nurse would not teach the client how to use the applicators to clear the ears. The nurse would not teach the client about basic anatomy and physiology of the ears. The option of potential infection from self-cleaning of ears is not correct.

A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?

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

During the health interview, a client reports an occasional blockage in the upper portion of the nasal passage. The nurse understands the most pronounced effect this would have on the client would be what?

Impaired sense of smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell. A decreased ability to taste would be associated with an upper respiratory infection or lesion of the facial nerve. Difficulty hearing or occasional dizziness is associated with ear and vestibular problems.

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

Impaired swallowing Explanation: Impaired swallowing is associated with problems in oral, pharyngeal, or esophageal structure or function. Related findings include delayed swallowing; gurgly voice; frequent coughing, choking, or gagging; inability to clear oral cavity; and food falling from the mouth. The scenario described does not mention impaired dentition, alteration in mobility, or altered cerebral perfusion.

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. 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.

During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom?

Inability to smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell. A decreased ability to taste would be associated with an upper respiratory infection or lesion of the facial nerve. Difficulty hearing or occasional dizziness are associated with ear problems.

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 Explanation: 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.

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

Inserting the speculum down and forward into the ear canal Explanation: 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.

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 Explanation: 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.

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

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

Which finding, if noted when inspecting a client's mouth, would require immediate follow-up?

Leukoplakia Explanation: Leukoplakia is a precancerous lesion that requires immediate follow-up. Although thrush, which indicates a candidal infection; Koplik spots, which are an early sign of measles; and canker sores, which are associated with adrenocortical insufficiency, are abnormal findings, the evidence of leukoplakia is serious and needs immediate evaluation.

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

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

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

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

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

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

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

On the mastoid process Explanation: 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.

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

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

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

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

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

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

What action should the nurse implement using an otoscope when assessing the ear of an adult client?

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.

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

Receding and ischemic gums Explanation: The gums recede, become ischemic, and undergo fibrotic changes as a person ages. A bifid uvula is a common finding in Native Americans, not among older adults. Brown spots on the chewing surface of teeth is an indication of tooth decay and is not associated with aging per se, nor are enlarged palatine tonsils, which are an indicator of tonsillitis.

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

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

After conducting a health history, the nurse decides to perform the assessment shown. What finding did the nurse use to make this clinical determination?

Reduced hearing in one ear Explanation: The Weber test is used to determine unilateral hearing loss. With conductive hearing loss, the client reports hearing the tuning fork sound better in the poor ear. With sensorineural hearing loss, the client hears the sound better in the good ear. The Weber test is not used to assess a sore throat. There are many reasons for a rigid tympanic membrane. A Weber test is used to test for hearing only. This test will not help diagnose the reason for edematous neck lymph nodes.

During a physical examination the nurse performs the action shown. What assessment is the nurse performing?

Rinne test Explanation: The first part of the Rinne test is to place the handle of a vibrating tuning fork on the mastoid process. This is assessing hearing through bone conduction. The Weber test is conducted by placing the handle of a vibrating tuning fork on the top of the head. It is used to differentiate the cause of unilateral hearing loss. Auditory acuity is determined through an audiogram in a soundproof room. Vestibular function or equilibrium is assessed through the Romberg test.

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. Explanation: 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.

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?

The client's neurological status Explanation: Deviation of the uvula or lack of movement of the soft palate suggests cranial nerve damage or stroke. Further neurological assessment and referral is necessary. This abnormal finding is not associated with immune, respiratory, or nutritional deficits.

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus Explanation: During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

A nurse is preparing a teaching session for a group of new parents about ear infections and measures to prevent them. The nurse is planning to address the reasons why children are more susceptible to these infections than adults. Which information would the nurse describe?

The size and shape of children's eustachian tubes makes them vulnerable. Explanation: 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 normally associated with putting things in their ears, immature immune systems, or poor hygiene.

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

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

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?

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

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

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

A client reports, "I feel like the whole room is spinning around me, and it makes me nauseous sometimes." What term should the nurse use to document the client's symptom?

Vertigo Explanation: Vertigo, the sensation of the room spinning, indicates dysfunction of the bony labyrinth in the inner ear. Dizziness indicates that the client feels like he/she is spinning in the room. Tinnitus, a sensation of buzzing in the ear, is thought to be an inability to filter internal noise from the external input of sound. Otalgia is ear pain.

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

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

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

The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?

Vitamin deficiency Explanation: A smooth and often sore tongue that has lost its papillae, sometimes just in patches, suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron. Candidiasis or white patches would be on the tongue if a yeast infection is present. The tongue may have black areas if antibiotics were recently used. The tongue would deviate from the midline if CN XII is damaged.

The submandibular glands open under the tongue through openings called

Wharton ducts. Explanation: The submandibular glands, located in the lower jaw, open under the tongue on either side of the frenulum through openings called Wharton's ducts.

The three salivary glands also contain drainage ducts. Which drainage ducts are associated with the submandibular gland?

Wharton's ducts Explanation: The submandibular gland is beneath the body of the mandible. Its Wharton ducts run deep to the floor of the mouth and open on both sides of the frenulum. The parotid (Stensen's) duct opens into the mouth in the buccal mucosa just opposite the upper second molar. The small sublingual salivary gland lies within the floor of the mouth under the tongue with many openings along the submandibular duct.

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?

XII Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve. The third cranial nerve is involved with eye muscle movement. The sixth cranial nerve is involved with lateral eye movement. The eighth cranial nerve is involved with hearing and equilibrium

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

don clean gloves for the procedure. Explanation: Before touching any mucous membranes the nurse should apply gloves.

A client tells the nurse that he is constantly congested in spite of using a decongestant at least twice daily. The nurse understands the client may be experiencing

rhinitis medicamentosa

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

touching each other. Explanation: 4+ Tonsils touch each other.