Ch. 15 Practice PrepU Questions

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

"Do you use tobacco, whether smoking or chewing?" Explanation: Cigarette, pipe, or cigar smoking and use of smokeless tobacco increase a person's risk for oral cancer. Dentists often screen for oral cancers, but poor dental hygiene is not an identified risk for the development of oral cancer. Recurrent mouth ulcers are not linked to the disease.

An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response? a) "You can wrestle after the lesions stop weeping and have crusted over." b) "As long as the lesions are covered, you can wrestle." c) "When the repeated cultures are clear, you may resume wrestling." d) "This condition is not contagious, so there is no need to stop wrestling."

"You can wrestle after the lesions stop weeping and have crusted over." Explanation: Herpes simplex virus is very contagious. Wrestling is a close contact sport, therefore the client should not wrestle until the lesions have stopped weeping and have fully crusted over. It's nearly impossible to cover lesions on the lips. Repeat cultures are not routinely performed for this condition.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and seen midway between the tonsillar pillars and the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? a) 1+ b) 2+ c) 3+ d) 4+

2+ Explanation: The nurse should document the tonsillar grading as 2+ because the tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones which are visible. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? a) 2+ b) 1+ c) 3+ d) 4+

3+ Explanation: The nurse should document the tonsillar grading as 3+ because the tonsils are enlarged and touching the uvula. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are just visible. Tonsils that are so enlarged that they touch each other are graded 4+.

A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and touching one another. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? a) 2+ b) 1+ c) 4+ d) 3+

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

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

A 77-year-old man who describes himself as being healthy Explanation: Receding gums are abnormal in younger clients; in older clients, the teeth may appear longer because of age-related gingival recession, which is common.

Which client would the nurse expect to be a greatest risk for chronic respiratory infections? a) A painter b) A teacher c) A mailman d) A waitress

A painter Explanation: A painter would be repeatedly exposed to fumes of irritating chemicals, such as paint and paint thinner, which may cause inflammation of the upper respiratory tract, predisposing the individual to chronic infections. The other individuals are not in high-risk occupations/professions.

A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes the client to be febrile with temperature 101.5° F, tonsils are 2+ and red, transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?

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

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to? a) Koplik's spots b) Traverse ridge c) Angular cheilitis d) Crusting

Angular cheilitis Explanation: Overclosure of the mouth may lead to maceration of the skin at the corners of the mouth; this condition is called angular cheilitis. It would not lead to Koplik's spots, a traverse ridge, or crusting

The Kiesselbach plexus is the most common site for what? a) Anterior nosebleeds b) Posterior nosebleeds c) Sinusitis d) Infections

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

A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding? a) "Do you drink a lot of coffee or tea?" b) "Are you experiencing any tooth pain?" c) "Do you have trouble chewing your food?" d) "How many cigarettes do you smoke daily?"

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

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client? a) "Are you taking high blood pressure medication?" b) "Do you have a family history of severe headaches?" c) "Are you experiencing sinus pressure and congestion?' d) "Have you ever had an injury to your head or neck?"

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

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

Ask the client about the timing of his allergy symptoms. Explanation: Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round. Transillumination and otoscopic examination will not help identify the cause of the client's allergy symptoms. Similarly, the response of the allergies to antihistamines will not determine the ultimate cause of the symptoms.

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? a) Ask the client to say "aaah" b) Press firmly on the back of the tongue c) Ask the client to stick out the tongue d) Depress the tongue slightly off center

Ask the client to say "aaah" Explanation: Asking the client to say "aaah" and instructing him or her to open the mouth wide makes the uvula more clear for observation. The nurse should depress the client's tongue slightly off center to prevent the gag reflex during observation of the uvula. Depressing the back of the tongue would elicit the gag reflex. Having the client stick out the tongue would not provide a clear view of the uvula

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the anterior portion of the tongue? a) Put on gloves and retract the client's lips and cheeks. b) Ask the client to stick the tongue out between the lips. c) Use a penlight and tongue depressor to retract the lips. d) Use a square gauze pad to hold the client's tongue to each side.

Ask the client to stick the tongue out between the lips. Explanation: Sticking the tongue out between the lips allows visualization of the anterior portion of the tongue. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's 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 client's lips and cheeks is a technique used to examine the gums and teeth.

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

Assess the client's cranial nerve function. Explanation: Fasciculations suggest cranial nerve damage, so the nurse would need to assess the client's cranial nerves. The finding is not suggestive of a nutritional deficiency, which would normally necessitate a diet recall. Fasciculations are not associated with medications or thyroid dysfunction.

The nurse is caring for a patient in the emergency department for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis? a) Keep the nasal passages clear. b) Use a tissue when blowing the nose. c) Avoid picking the nose. d) Use a dehumidifier.

Avoid picking the nose. Explanation: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose bleeding, straining, high altitudes, nasal trauma (nose-picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis.

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching? a) "Use a humidifier to increase the moisture in the environment." b) "Make sure to get lots of vitamin from the sun." c) "Increase your intake of foods high in iron and zinc." d) "Avoid substances that could be irritating to your mouth."

Avoid substances that could be irritating to your mouth." Explanation: Leukoplakia is precursor to oral cancer. The nurse would instruct the client to avoid substances that could be irritating to the mouth. The nurse would also instruct the client to eat a healthy, balance diet, including fruits and vegetables that are high in vitamin A (vitamin A deficiency is a risk factor for oral cancer). The client also needs to be instructed in avoiding excessive exposure to sunlight and ultraviolet light. Using a humidifier would be appropriate to help prevent sinusitis

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) Both sides c) Posteriorly near tonsils d) Frenulum

Both sides Explanation: The sides of the tongue are the most common area for tongue cancer to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity.

A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client? a) Smoking cigarettes b) Chewing betel nuts c) Heavy alcohol use d) Infection with human papillomavirus

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

A line across the tip of the nose is seen in an 8-year-old client. The nurse would focus on which area of assessment? a) Mucosal polyps b) History of abuse c) Chronic nose picking d) Chronic allergies

Chronic allergies Explanation: A line across the tip of the nose just about the fleshy tip is common in clients with chronic allergies. This finding is not associated with a history of abuse, chronic nose picking, or mucosal polyps.

The nurse identifies this as trapping debris and propelling it toward the nasopharynx. a) Tubinates b) Columella c) Cilia d) Lacrimal duct

Cilia Explanation: Cilia capture and propel debris toward the nasopharynx. Turbinates are bony lobes that project from the lateral walls of the nasal cavity. The lacrimal duct receives drainage. Th columella divides the nostrils

An Asian American primipara asks to speak with the nurse about a concern she has over potential genetic defects in her fetus. What congenital problem would the nurse expect questions about based on the patient's ethnicity? a) Down syndrome b) Spina bifida c) Transposition of the great vessels d) Cleft lip and palate

Cleft lip and palate Explanation: Cleft lip and palate have increased incidence in Native and Asian Americans. Down syndrome is not known to be of higher incidence in Asian Americans. Spina bifida would be a concern if the patient had not been taking folic acid. Transposition of the great vessels is not known to be of higher incidence in Asian Americans.

The nurse is assessing an individual with facial injury following a motor vehicle accident. Which finding would suggest a fracture of the nose? a) polyps b) mucus c) turbinates d) crepitus

Crepitus Explanation: The presence of crepitus, a crackling or grating sound, is suggestive of a fractured nose. Polyps are grape-like swollen nasal membranes. Mucus is suggestive of infection. The turbinates are normal structures of the internal nose.

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? a) Either side of the frenulum on the floor of the mouth b) Right side of the frenulum at the base of the gums c) Posterior aspect of the tongue bilaterally d) Buccal mucosa across from the second upper molars

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.

On examining a client, the nurse detects a sulfur odor to the breath. The nurse recognizes this finding as a characteristic of which disease process? a) Respiratory infection b) Small bowel obstruction c) End-stage liver disease d) Diabetic ketoacidosis

End-stage liver disease Explanation: Clients with end-stage liver disease have a sulfur odor in their breath. The nurse should suspect the client of having diabetic ketoacidosis if the breath has a fruity smell. Clients with small bowel obstructions have a fecal smell, and clients with respiratory infection have foul odors on their breath

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment? a) Red, bleeding b) A grey-white line c) Pink, moist, firm d) Enlarged, reddened

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

A client diagnosed with Sjogren syndrome should be given which instructions? a) Taking mucus thinning medication can relieve symptoms. b) Blood pressure should be checked frequently. c) Condom use can reduce the risk of transmission. d) Eye drops and sucking on hard candy may used to relieve dryness.

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.

The nurse notes weeping pustules in the oral cavity, which the patient reports as painful. Which condition does the nurse suspect the patient has? a) Leukoplakia b) Candidiasis c) Strep throat d) Herpes simplex virus

Herpes simplex virus Explanation: Herpes simplex virus is transmitted by direct contact with an infected person and is characterized as a painful oral lesion that evolves into pustules that rupture, weep, and crust, usually at a lip-skin juncture. Leukoplakia is a white oral lesion that is firmly attached to the mucosa. Candidiasis can occur in newborns, immunosuppressed individuals, and following antibiotic or corticosteroid therapy and is a white sticky mucus on the tongue or oral mucosa. Clinical manifestations of strep throat include fever, a red sore throat with exudate, dysphagia, and enlargement of jaw and neck lymph nodes.

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information? a) Frequency of nosebleeds b) History of dysphagia c) History of allergies d) Tonsillar enlargement

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. Dysphagia would suggest a problem with the throat. 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.

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? a) History of allergies b) Prolonged tonsillar enlargement c) History of epistaxis (nosebleeds) d) Incomplete immunization record

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.

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

How often do you use over-the-counter nasal sprays?" Explanation: Overuse of nasal sprays may cause nasal irritation, nosebleeds, and rebound swelling. These symptoms are not characteristic of poor nutrition or heavy alcohol use. Acetaminophen does not result in bleeding or chronic nasal congestion.

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

Inability to breathe through the nose may indicate sinus congestion, obstruction, or a deviated septum. It would not be necessary to ask if the client experiences dry mouth often; the client would most likely answer yes. Tonsillar inflammation would most likely be unrelated to the client's breathing through the mouth. A focused respiratory assessment is not necessarily required, since mouth breathing does not usually affect respiratory function.

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? a) Inspect the nostrils with an otoscope b) Assess for allergies to antibiotic c) Have the child blow the nose to assess drainage d) Reassure the mother that this is common in children

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.

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

Intravenous fluid replacement Explanation: Deep tongue fissures are seen in dehydration, so intravenous fluid therapy would be a priority. Chest x-ray may be indicated if the client exhibited cyanosis or respiratory difficulties. A complete blood count would not show the effects of dehydration as clearly as an electrolyte analysis. Dietician referral might be indicated if the assessment revealed a nutritional deficiency.

A patient comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? a) Sinuses b) Kiesselbach plexus c) Wharton ducts d) Thompson plexus

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

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

Pain on percussion Explanation: The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection. Percussion is not performed in an effort to gauge particular sounds.

A client presents to the health care clinic complaining of a sore throat. In examining the client's mouth and throat, the nurse notices that the tonsils on both sides of the oropharynx at the end of the soft palate are swollen. Which tonsils are these? a) Palatine b) Paranasal c) Lingual d) Pharyngeal

Palatine Explanation: Masses of lymphoid tissue referred to as the palatine tonsils are located on both sides 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.

On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client? a) Native American heritage b) Tonsil infection c) Paralysis of cranial nerve X (vagus) d) Cerebrovascular accident

Paralysis of cranial nerve X (vagus) Explanation: Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A bifid or split uvula is a common finding in the Native American population. A cerebrovascular accident may cause asymmetrical or loss of movement of the uvula. Infection of the tonsils does not cause a deviation of the uvula and failure of the palate to rise

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

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.

The nurse observes a white patchy area in the pharyngeal fossa of a client. What is the nurse's best action? a) Instruct the client to gargle with saline until area is gone. b) Explain the post surgical care after tonsillectomy. c) Prepare client for a biopsy of the lesion. d) Tell client to take antibiotics as directed.

Prepare client for a biopsy of the Explanation: The phayngeal fossa is the most common site of oral cancer. A whitish area is a suspicous finding and will likely be biopsied. Gargling with saline and antibiotics are not recommended. This finding does not indicate a need for a tonsillectomy. Indications for tonsillectomy are repeated tonsillitis and/or tonsil hypertrophy.

Which technique should the nurse use to examine the sinuses of a client with a sinus infection? a) Inspect the frontal and maxillary sinuses with an otoscope b) Press up on the brow on each side of the nose to palpate the frontal sinus. c) Indirectly percuss over the cheekbones for dullness or pain d) Insert a penlight into the oral cavity & angle it toward the roof of the mouth

Press up on the brow on each side of the nose to palpate the frontal sinus. Explanation: Objects should not be placed in the client's 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 press up on the brow on each side of the nose to palpate the frontal sinus. Frontal and maxillary sinuses cannot be examined through an otoscope. Sinus cavities are not indirectly percussed but may be tapped lightly to detect pain.

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the gums and teeth? a) Put on gloves and retract the client's lips and cheeks. b) Use a penlight and tongue depressor to retract the lips. c) Use a square gauze pad to hold the client's tongue to each side. d) Ask the client to stick the tongue out between the lips.

Put on gloves and retract the client's lips and cheeks. Explanation: Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.

Which instructions should the nurse provide to the client taking a sublingual medication? a) Put the medication underneath your tongue. b) The medication is placed inside the cheek. c) Let the medication dissolve on your tongue. d) Place the medication along the roof of the mouth.

Put the medication underneath your tongue. Explanation: The highly vascular floor of the mouth is a good location for absorption of sublingual medications. The client should be taught to place the medication under the tongue for best absorption.

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? a) Enlarged palatine tonsils b) Brown spots on the chewing surface of teeth c) Bifid uvula d) Receding and ischemic gums

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.

Which assessment of the tongue should a nurse recognize as abnormal? a) Pale pink and moist b) Ventral surface with visible veins c) Red with loss of papillae d) Fissured, topographical pattern

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 normal tongue has visible veins on the ventral surface and is pink or pale in color and moist. A normal variation seen in the older client is a fissured, topographical map-like tongue.

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? a) Red, bleeding b) A grey-white line c) Enlarged, reddened d) Pink, moist, firm

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

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

Refer the client to a primary care provider for medication. Explanation: The thick, white plaques are suggestive of yeast infection, requiring treatment with medication. These often occur in clients with HIV, but this is not the most common cause of oral candidiasis. Loss of taste discrimination would indicate a possible zinc deficiency. The finding is not associated with liver dysfunction, which would necessitate assessment for jaundice

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

Referring the client for further evaluation Explanation: A bluish-black line along the gum line is seen in lead poisoning. Therefore the nurse needs to refer the client for further evaluation. Phenytoin therapy can lead to gingival hyperplasia. Smoking may cause yellowish or brown teeth or a yellow-brown coating on the tongue. The finding is not suggestive of inadequate mouth care. However, information about proper mouth care would be important for any client, regardless of the findings.

On examining a client, the nurse detects a foul odor to the breath. The nurse recognizes this finding as a characteristic of what disease process? a) End-stage liver disease b) Small bowel obstruction c) Respiratory infection d) Diabetic ketoacidosis

Respiratory infection Correct Explanation: Clients with respiratory infection have foul odors in their breath. The nurse should suspect the client of having diabetic ketoacidosis if there is a fruity smell to his breath. Clients with end-stage liver disease have a sulfur odor in their breath. Clients with small bowel obstructions have a fecal smell.

A patient's spouse reports to the nurse that the patient sometimes stops breathing during sleep and asks if this is serious. What is the best response by the nurse? a) "Everyone experiences periods of apnea when they are in deep REM sleep." b) "Your spouse has sleep apnea, which can cause problems with blood pressure." c) "Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." d) "Your spouse is suffering from a normal condition of aging known as sleep apnea."

Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." Explanation: Individuals with sleep apnea are at risk for hypertension, heart attack, brain attack (stroke), and motor vehicle accidents. While the response where the nurse states sleep apnea causes problems with blood pressure is correct, it is not specific in what the problem is: hypertension. As we age, the risk for sleep apnea increases, but sleep apnea is not a normal part of aging and the response does not answer the spouse's question. Sleep apnea is not an expected finding of REM sleep.

In examining a client's mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following? a) Wharton's ducts b) Stenson's ducts c) Burton's ducts d) Foster's ducts

Stenson's ducts Explanation: Stenson's 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 moistness in area. Wharton's ducts are openings from the submandibular salivary glands and are located on either side of the frenulum on the floor of the mouth. Foster's and Burton's are not the names of actual ducts.

The patient comes to the clinic with complaints of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which condition does the nurse suspect the patient has? a) Pharyngitis b) Strep throat c) Leukoplakia d) Gingivitis

Strep throat Explanation: Clinical manifestations of strep throat include fever, a red sore throat with exudate, dysphagia, and enlargement of jaw and neck lymph nodes. Leukoplakia is a white oral lesion that is firmly attached to the mucosa. Clinical manifestations of Pharyngitis include fever, a red sore throat with exudate, dysphagia, anorexia, and rash; the jaw and neck lymph nodes are not enlarged. Gingivitis is characterized by red, swollen, possibly bleeding gums

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

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

An anatomy instructor is discussing the nose with the nursing class. How would the instructor identify the ostiomeatal complex? a) The superior turbinate and middle meatus area b) The superior turbinate and inferior meatus area c) The middle turbinate and inferior meatus area d) The middle turbinate and middle meatus area

The middle turbinate and middle meatus area Explanation: The middle turbinate and middle meatus receive drainage from the frontal sinus, anterior ethmoid sinus, and maxillary sinuses. The site where the frontal, ethmoid, and maxillary sinuses empty into the nasal cavity is known as the ostiomeatal complex.

The nurse is assessing the older adult for anosomia. Which nursing action would the nurse perform? a) The nurse instructs the older adult to say "ah." b) The nurse inspects the buccal mucosa and tongue. c) The nurse asks the client to identify common scents. d) The nurse palpates the maxillary sinus areas.

The nurse asks the client to identify common scents. Explanation: Anosomia is a loss of smell. The nurse would ask the client to identify common scents. The nurse instructs the older adult to say "ah" to assess the function of the vagus nerve (CN X). Palpation of the maxillary sinus areas should not elicit tenderness or fullness, which are suggestive of infection (sinusitis). The nurse would inspect the buccal mucosa and tongue to identify poor oral hygiene, infection, and trauma

The nurse is assessing the client's hypoglossal nerve (CN XII). Which nursing action would the nurse perform? a) The nurse gently places a tongue blade on the posterior tongue. b) The nurse instructs the client to identify common scents on a sniff card. c) The nurse instructs the client to smile and show upper and lower teeth. d) The nurse instructs the client to say "ah" and notes a rise of the uvula.

The nurse gently places a tongue blade on the posterior tongue. Explanation: The nurse gently places a tongue blade on the posterior dorsum to assess the function of the hypoglossal nerve (CN XII). The nurse would ask the client to identify common scents to assess the olfactory nerve (CN I). The nurse assesses the facial nerve (CN VII) by instructing the client to smile and then show teeth. The nurse instructs the older adult to say "ah" to assess the function of the vagus nerve (CN X).

Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding? a) Paralysis of cranial nerve X (vagus) nerve is likely to be present b) This is often a normal finding in the Native American population c) The client should be assessed for a cerebrovascular accident (CVA) d) Enlargement of the tonsils with infection is a common cause

This is often a normal finding in the Native American population Explanation: A bifid or split uvula is a common finding in the Native American population. Clients with a bifid uvula may have a submucous cleft palate. Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A CVA may cause asymmetrical or loss of movement of the uvula. Enlargement of the tonsils does not cause a bifid uvula.

The nurse is performing a physical assessment of a client who complains of a sore throat and stuffy nose. The nurse notes a red inflamed throat and slight fever and suspects strep. Which of the following tests would be ordered to confirm this diagnosis? a) Pulmonary function test b) Bronchoalveolar lavage c) Sputum specimen d) Throat culture

Throat culture Explanation: A throat culture may be done within a matter of hours to rule out the presence of streptococci. The pulmonary function test (PFT) measures how much air a client inhales (inspiration) and exhales (expiration) in one breath and assesses the client's general respiratory status. Bronchoalveolar lavage is most often used to diagnose pulmonary tuberculosis. Sputum specimens help determine the presence of organisms or blood in a person's sputum

The nurse teaches the client that overuse of this medication can cause rebound nasal congestion. a) Antihistamines b) Anticoagulants c) Topical decongestants d) Antidepressants

Topical decongestants Explanation: Topical decongestants can cause rebound nasal congestion. Anticoagulants may cause epistaxis. Antihistamines and antidepressants can cause drying of the mucous membranes.

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? a) Torus palatinus b) Thrush (candidiasis) c) Kaposi's sarcoma d) Leukoplakia

Torus palatines 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.

During an examination of the oral cavity, which technique by the nurse is most likely to improve visualization of the buccal mucosa? a) Ask the client to stick the tongue out between the lips. b) Use a penlight and tongue depressor to retract the lips. c) Put on gloves and retract the client's lips and cheeks. d) Use a square gauze pad to hold the client's tongue to each side.

Use a penlight and tongue depressor to retract the lips. Explanation: Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Putting on gloves and retracting the client's 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

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue? a) Use a penlight and tongue depressor to retract the lips b) Ask the client to stick the tongue out between the lips c) Use a square gauze pad to hold the client's tongue to each side d) Put on gloves and retract the client's lips and cheeks

Use a square gauze pad to hold the client's tongue to each side Explanation: The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's 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 client's 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.

Which cranial nerve is associated with the movement of the uvula? a) Facial (CN VII) b) Vagus (CN X) c) Trigeminal (CN V) d) Glosspharyngeal (CN IX)

Vagus (CN X) Explanation: The vagus nerve (CN X) can be evaluated with the assessment of the uvula.

During the nursing assessment, the nurse identifies the client has a smooth, glossy tongue. The nurse understands this is caused by what? a) Poor oral care b) Sun exposure c) Accumulation of food d) Vitamin B12 deficiency

Vitamin B12 deficiency Correct Explanation: A smooth red, glossy tongue is caused by a vitamin B12 deficiency. Food accumulation in the fissures is known as scrotal tongue.

The nurse notes a brown hairy coating on the tongue when assessing the oral cavity of the patient. Which medication would the nurse suspect as the causative agent when reviewing the patient's medications? a) amoxicillin (Amoxil) b) ketoconazole (Nizoral) c) acyclovir (Zovirax) d) albendazole (Albenza)

amoxicillin (Amoxil) Explanation: Brown/black hairy tongue is a fungal infection of the tongue and may occur following use of an antibiotic, such as amoxicillin (Amoxil). Brown/black hairy tongue is not a side effect of anthelminitics, antivirals, and antifungals. Albendazole (Albenza) is used to treat parasitic worms. Acyclovir (Zovirax) is used to treat viral infections. Ketoconazole (Nizoral) is an anti-fungal agent.

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the a) area underneath the tongue. b) area near the salivary glands. c) inside of the cheeks. d) area on top of the tongue.

area underneath the tongue. Explanation: The area underneath the tongue is the most common site of oral cancer.

The nurse is performing the admission assessment of a newborn to the nursery. Which finding noted by the nurse requires further evaluation? a) sucking tubercle b) choanal atresia c) milia on the nose d) Epstein pearls

choanal atresia Explanation: Choanal atresia is a congenital disorder where one nostril is not patent and can cause respiratory distress in a newborn. Epstein pearls are small, white, glistening, pearly papules along the median border of the hard palate and gums and are a normal finding in infants. Small white bumps or milia across the bridge of the nose are a normal finding in infants. A small pad of tissue in the middle of the upper lip known as the sucking tubercle is a normal finding in infants.

The client reports two nosebleeds in the past week. Which medication taken by the client would the nurse suspect is contributing to the nosebleeds? a) clopidogrel (Plavix) b) lithium (Eskalith) c) levothyroxine (Synthroid) d) omeprazole (Prilosec)

clopidogrel (Plavix) Explanation: Anticoagulants, such as clopidogrel (Plavix), may predipose patients to nosebleeds or exacerbate bleeding. Nosebleeds are not a side effect of omeprazole (Prilosec), levothyroxine (Synthroid), or lithium (Eskalith)

Before examining the mouth of an adult client, the nurse should first a) don clean gloves for the procedure. b) ask the client to leave dentures in place. c) don sterile gloves for the procedure. d) offer the client mouthwash.

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

When assessing a patient the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils? a) Tonsils are T3 b) Tonsils are T2 c) Tonsils are T1 d) Tonsils are T4

tonsils are T3 Explanation: Tonsils are graded based on size: T1: tonsils are visible; T2: tonsils are between the tonsillar pillars and the uvula; T3: tonsils are touching the uvula; T4: tonsils are touching each other.

The patient acknowledges inhaling cocaine on a weekly basis. Which structure would the nurse assess for damage? a) palatine tonsils b) nasal mucosa c) oral mucosa d) teeth and tongue

nasal mucosa Explanation: Inhaling cocaine may permanently damage the nasal mucosa and the lining of the upper airway. Marijuana may damage the cilia. Methamphetamine may severely damage the teeth. Inhaling cocaine does not damage the palatine tonsils.

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

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 patient may drink during meals unless explicitly contraindicated.

The nurse assess the client for common upper respiratory symptoms which may include what? Select all that apply. a) Nasal congestion b) Pharyngitis c) Pain when breathing d) Hoarseness e) Fever

• Hoarseness • Pharyngitis • Nasal congestion Explanation: Common signs of an upper respiratory infection include hoarseness, nasal congestion and pharyngitis. Fever and pain when breathing are not commonly associated with an upper respiratory infection.

A patient is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this patient's symptom? (Select all that apply.) a) Press down on the lower jaw. b) Press up on the maxillary sinuses. c) Press up on the frontal sinuses from under the bony brows. d) Press up on the area next to the ear. e) Press down on the head.

• Press up on the frontal sinuses from under the bony brows. • Press up on the maxillary sinuses. Explanation: Only the frontal and maxillary sinuses are readily accessible to physical examination. To assess for sinus tenderness, the nurse should press up on the frontal sinuses from under the bony brows and press up on the maxillary sinuses. Pressing down on the head, pressing on the area next to the ear, and pressing down on the lower jaw are not techniques to assess the frontal and maxillary sinuses.

A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply. a) Salts b) Proteins c) Mucus d) Amylase e) Fats

• Salts • Mucus • Amylase Explanation: The secretion of the salivary glands is saliva, which is a watery serous fluid containing salts, mucus, and salivary amylase. Saliva lacks protein and fat.

Which glands are responsible for mouth drainage? Select all that apply. a) Parotid b) Sebaceous c) Lacrimal d) Sublingual e) Submandibular

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

The nurse is teaching at a community clinic. She explains to the clients that what increases the risk for head and neck cancer? Select all that apply. a) Pet dander b) Mold c) Tobacco products d) Alcohol e) Pollens

• Tobacco products • Alcohol Explanation: Smoking an alcohol have been associated with excessive use of alcohol and tobacco products. Mold, pollen and pet dander are allergens

Which clinical manifestation would the nurse expect to find when assessing the patient with pharyngitis? Select all that apply. a) fever b) epistaxis c) exudates d) aphasia e) dysphagia

• exudates • fever • dysphagia Explanation: When assessing the patient with pharyngitis, the nurse would expect the clinical manifestations of fever, dysphagia, and exudates in addition to sore throat, malaise, anorexia, redness of the pharyngeal walls, and rash. Aphasia, the inability to understand or express speech, and epistaxis or nosebleed would not be expected clinical manifestations of pharyngitis

The nurse is assessing the patient with gastroesophageal reflex disease. Which clinical manifestations would the nurse include in the history? Select all that apply. a) voice changes b) halitosis c) anosmia d) cough e) dysphagia

• voice changes • cough • dysphagia Explanation: Clinical manifestations of gastroesophageal reflex disease include heartburn, cough, dysphagia, and voice changes. Anosmia is the loss of smell, whereas halitosis is bad breath. Anosmia and halitosis are not clinical manifestations of gastroesophageal reflex disease