The point ch 18: assessing mouth, throat

A nurse is working with a client who has an impaired ability to smell. He explain 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? A) Cranial nerve I B) Cranial nerve V C) Cranial nerve VII D) Cranial nerve IX

A) Cranial nerve I Exp: Receptors of cranial nerve I are located in the nose. These receptors are related to the sense of smell. Cranial nerve V VII IX and XII assist with some functions related to ingestion taste preparing food for digestion and speech

A nurse inspects the gums and teeth of a middle age adults and notices the presence of small brown spot on the chewing services of several of the molar teeth. What question should the nurse asked client to determine because of these findings? A) are you experiencing any toothh pain B) How many cigarettes do you smoke daily C) do you drink a lot of coffee or tea D)Do you have trouble chewing your food

A) are you experiencing any tooth pain Explanation: brown spot on the chewing surface of the teeth might indicate tooth decay which may also 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 client is brought to the emergency department in a confused state. Upon examination of the client smell the nurse to text a fruity odor to the breath.The nurse recognize these findings as a characteristic what disease process? A)diabetic ketoacidosis B) respiratory infection C) end stage liver disease D) small bowls obstruciton

A) diabetic ketoacidosis Explanation: the nurse should suspect the client of having diabetic Keto acidosis on the Basis of the fruity smell of his breath. Clients with end-stage liver disease have a sulfur odor in their bed. Client with small ball obstruction have a fecal smellAnd clients with the respiratory infections help out odors in their breath

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 Whartons ducts? A) either side of the frenulum on the floor of the mouth B) Buccal mucosa across from the second upper molars C) Right side of the frenulum at the base of the gums D) Posterior aspect of the tongue bilaterally

A) either side of the frenulum on the floor of the mouth Exp: the nurse should inspect the wharton ducts on either side of the frenulum on the floor of the mouth. stensons ducts not the wharton 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 site to inspect for salivary ducts

Which characteristics of the gums should a nurse expect to assess in a client who experiences an adverse affects of phenytoin treatment? A) enlarge reddened B) a grey white line C) red bleeding D) pink moist firm

A) enlarges reddened Explanation: the nurseMay find enlarged reddened gums in the client as an adverse effect of the treatment. Pink moist firm gums are normal findings of the gums. Red swollen and bleeding gums are seen in gingivitis scurvy and leukemia. A gray white line along the gumline is seen in cases of lead poisoning

Which action by the nurse is appropriate to prevent the gag reflex during observation of the uvula? A)Depress the tongue slightly off center B) tell the clients to open the mouth wide C) pressed firmly on the back of the tank D) Ask the client to say ahhh

A)depress The tongue slightly off center Exclamation. The nurse should depress the client tongue off center to prevent the gag reflex during observation of the uvula. Asking the client to say ahhh and instructing him or her to open the mouth wide makes it more clear for observation but does not prevent the gag reflex. depressing the back of the tongue would elicit the gag reflex

A client presents to the healthcare 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? A) are you taking high blood pressure medication B) are you experiencing sinus pressure and congestion C) do you have a family history of severe headaches D) Have you ever had an injury to your head or neck

B) Are you experiencing sinus pressure and congestion Explanation: the client has a recent onset a frontal headache in the nation 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

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? A) exposure to the sun B) asthma C) Heavy alcohol use D) chewing betel nuts

B) Asthma Exp: This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, COPD, an immune system disorder, hay fever, asthma and regular exposure to pollutants such as cigarette smoke. The other answer listed are all risk factors for oropharyngeal cancer but not for sinusitis

A client presents to the healthcare clinic with reports of three day history of fever sore throat and trouble swallowing. The nurse notes the client To be febrile With temperature 101.5f tonsil 2+ and red transillumination of the sinuses is normal . Which nursing diagnosis should the nurse confirm based I this data A) ineffective health maintenance B) acute pain C) impaired swallowing D) self care deficit

B) acute pain Explanation: the nursing diagnosis of acute pain can you confirm because it meets the. Manger defining characteristics of verbalization of sore throat. Impaired swallowing is not related to him. Neurological or neuromuscular function. There is no criterion to confirm this client cannot maintain health maintenance because this is an acute problem. No doubt exist to confirm the nursing diagnosis of self-care deficit

The client reports a 20 pack per year history of cigarettes smoking. To assess this client for cancer where should the nurse inspect a tongue? A) at the very tip B) both sides C) frenulum D) posteriorly near tonsils

B) both sides Explanation: the signs of the tongue are the most common area for carcinoma to occur. Tobacco use is the most common respect her for the development of cancer of the oral cavity. The nurse should inspect all surfaces of the tongue and buccal mucosa for the presence of oral cancer

A nurse is examining a client who is complaining of sinus pressure in the 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? A) Ethmoidal B) Maxillary C) Sphenoidal D) Frontal

B) maxillary Exp: Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has ta large amount of exudate, you may fell crepitus upon palpation over the maxillary sinuses, which are located in the upper jaw. The ethmoidal and sphenoidal sinuses are smaller located deeper in the skull and are not accessible for examination,

A client who is semi conscious is brought to the emergency department of a healthcare facility after being rescued from a fire. Which findings of the lips support the diagnosis of carbon monoxide poisoning? A)swelling B) reddish C) cyanotic D) pallor

B) reddish Explanation: the finding of Reinisch lip supports the diagnosis of carbon monoxide poisoning. Cyanotic Lips are seen in cases of cold or hypoxia. Palora around the lips is a find it in clients with anemia in shock. Swelling of the lips is common in local or systematic allergic reactions

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? A) Prone with arms relaxed at the sides B) sitting with the head errect and at the eye level of the nurse C) tilting the head backwards with the neck flexed D) Semi-recumbent position with the chin lifted

B) sitting with the head errect and at the eye level of the nurse Exp: The nurse should ask the client to assume a sitting position with the head of errect and at the eye level of the examiner. Tilting the head backwards and 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

In examining a client mouth with a penlight, the nurse notice salivary ducts that are visible on the buccal mucosa across from the second upper molar. The nurse recognizes these as which of the following? A) Wharton ducts B) Stenson ducts C) Foster ducts D) Burton ducts

B) stenson ducts exp: Stenson ducts (parotid ducts) are located on the buccal mucosa across from the second upper molars and in a healthy mouth are visible with flow of saliva and with no redness swelling pain or moistenss in area. Wharton ducts are opening rom the submandibular salivary glands and are located on either side of the frenulum on the floor of the mouth. Fosters and burtons are not the names of actual ducts

During examination of the oral cavity, which technique by the nurse is appropriate to examine the side of the tongue? A) Ask the client to stick the tongue out between the lips B) use a square gauze pad to hold the clients tongue to each side C) Put on gloves and retract the clients lips and cheeks D) Use a penlight and tongue depressor to retract the lips

B) use a square gauze pad to hold the clients tongue to each side Exp: The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client tongue to each side. using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Putting on gloves and retracting the clients lips and cheeks is a technique used to examine the gums and teeth. sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue

A client present to the health care clinic complaining of a sore throat. In examining the clients mouth and throat , the nurse notices that the tonsils on both side of the oropharynx at the end of the soft palate are swollen. Which tonsils are these? A) Lingual B) Palatine C) Paranasal D) Pharyngeal

B)Palatine exp: Masses of lymphoid tissue referred to as the palatine tonsils are located on both side of the oropharynx at the end of the soft palate between the anterior and posterior pillars. The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils or adenoids are found high in the nasopharynx. Paranasal refers to sinuses, not tonsils

Which technique should the nurse used to examine the sinuses of a client with a sinus infection? A) insert a pen light in to the oral cavity in England towards the roof of the mouth B)Press up on the brow of each side of the nose to palpate the frontal sinus C)Inspect the frontal and maxillary sinuses with an Otoscope D) Indirectly progress over the cheekbones for dullness or pain

B)Press up on the brow of each side of the nose to palpate the frontal sinus Explanation: object should not be placed in the clients mouth unless necessary. Illumination of the frontal sinuses can be accomplished by placing the penlight on the brow of each side of the nose. The nurse should pass up on the bow of each side of the nose to palpate the frontal sinus. Frontal and maxillary sinuses cannot be examined through otoscope. Sinus cavities are not indirectly percussed but may be tapped like lightly to detect pain

A nurse is interviewing a client whose chief complaint is TMJ pain. Which of the following question should the nurse ask regarding a causative factor? A) How often do you brush and use dental floss B) Do you drink alcohol C) do you grind your teeth D) Is there a history of mouth cancer in your family?

C) Do you grind your teeth? Exp: Grinding the teeth ( bruxism) may be a sign of stress or of slight malocclusion. The practice may also precipitate TMJ problem and pains. The other answers are not causative factors associated with TMJ pain

A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesion on the lips. The nurse inspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client? A) Frequent pipe smoking B) Infection with hep C C) heavy use of alcohol D) being exposed to sunlight E) high consumption of cashew nuts F) being female

C) Heavy use of alcohol, A) frequent pipe smoking exp: Risk factor associated with oropharyngeal cancer are as follows: using tobacco products, heavy alcohol use, chewing betel nuts, infection with a certain type of human papillomarvirus (not hep C) being exposed to sunlight (lip cancer only, which this client shows no sign of ) being male (not female) fair skin, poor oral hygiene, poor diet/nutrition and a weakened immune system

A nurse is assessing the mouth of an older client. Which of the following finding is common among older adults? A) Browns spots on the chewing surface of teeth B) Enlarged palatine tonsils C) receding and ischemic gums D) Bifid uvula

C) receding and ischemic gums Exp: 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

A child present to the health care facility with new onset of a foul smelling purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is the appropriate action by the nurse? A) Reassure the mother that this is common in children B) Assess for allergies to antibiotics C) Have the child blow the nose to assess drainage D) Inspect the nostril with an otoscope

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

A client 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? A) At the very tip B) posteriorly near tonsils C) Frenulum D) both sides

D) both side Exp: The sides of the tongue are the most common area for the tongue cancer to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity.

An elderly client diagnosed with sinusitis undergoes transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which Precaution should the nurse take to avoid an inaccurate result? A)Hold the light source below the eyebrow B) lightly tap with fingers over at the maxillary sinus C) dim the lights in the room during examination D)Instruct the client to remove upper dentures

D) instruct the client to remove upper dentures Explanation: the nurse should instruct the client to remove upper dentures during transillumination of the maxillary sinuses. The presence of upper dentures in the client can block the light giving a false results. The light source is held below the eyebrow during transillumination of the frontal sinuses. Tapping the sinuses lightly is done during percussion of the sinuses. The lights in the examination room should be put off doing examination.

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect fine don't assessment I have a client with upper respiratory tract infection? A) dark pink moist and free of discharge B) Pale pink swollen with water exudate C)Bluish gray swollen with watery exudate D)Red swollen with Purulent discharge

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

Which assessment of the tongue should a nurse recognize as abnormal? A) fissures topographical pattern B) ventral surface with visible veins C) pale pink and moist D) red with loss of papillae

D) red with loss of papillae Explanation: A smooth red shiny tongue without papillae is indicative of a loss of vitamin B 12 or Niacin. The normalTongue has visible veins on the ventral side and it's pink or pale in color and moist a normal variation seen an older client is a fissured or a topographical map like tongue

A nurse examines A client with complaints of a sore throat and find that the tonsils are enlarged and seen midway between the tonsillar pillars and the uvula. Using and grading scale of 1+ the 4+how should the nurse appropriately document the tonsils? A)3+ B)1+ C)4+ D)2+

D)2+ ExplanationCalling the nurse should document the tonsillar greeting as 2+ because the tonsils are midway between the tonsil a pillar's and the uvula. Grade one tonsils are ones which are visible. Tonsils the touch the uvula graded 3+ and tonsils are so in large the touch each other and graded 4+

During examination of the oral cavity which technique by the nurse is appropriate to examine the tongue? A) use a pen light and tongue depressor to retract lips B) ask the client to stick that tongue out between the lips C) Put on gloves and retract the clients lips and cheeks D)Use a square gauze pad to hold the clients tongue to each side

D)Use a square gauze pad to hold the clients tongue to each side Explanation: the correct technique to examine the sides of the tongue is to use a square gauze pad told the clients tongue to each side. Using a pen my intent to pass her to retract the lips helps and visualization of the Buccal mucosa. Putting on gloves and retracting the clients lips and cheeks is a technique used to examine the gums and teeth. Stick in the tongue out between the lips only allows visualization of the anterior portion of the tI guess