Ch. 16 Nose, mouth and throat

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of: a.Dehydration. b.Irritation by gastric juices. c.A normal oral assessment. d.Side effects from nausea medication

A Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.

During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? Select all that apply. a.Chronic alcohol use b.Cigarette smoking c.Frequent episodes of strep throat d.Chronic allergies e.Aging f.Herpes simplex virus I

B, D, E The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a.Hypertrophy of the gums b.Increased production of saliva c.Decreased ability to identify odors d.Finer and less prominent nasal hair

C The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a.Rubella b.Leukoplakia c.Rheumatic fever d.Scarlet fever

C Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.

The nurse is performing an oral assessment on a 40-year-old Black patient and notices the presence of a 1 cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true? This lesion is: a.Leukoedema and is common in dark-pigmented persons. b.The result of hyperpigmentation and is normal. c.Torus palatinus and would normally be found only in smokers. d.Indicative of cancer and should be immediately tested.

A Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in Blacks.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: a.Acquired immunodeficiency syndrome (AIDS). b.Measles. c.Leukemia. d.Carcinoma.

A Oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with AIDS.

When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: a.Smooth glossy dorsal surface. b.Thin white coating over the tongue. c.Raised papillae on the dorsal surface. d.Visible venous patterns on the ventral surface.

A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas may indicate atrophic glossitis (see Table 16-5).

The salivary gland that is the largest and located in the cheek in front of the ear is the _________ gland. a.Parotid b.Stensen's c.Sublingual d.Submandibular

A The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw. The Stensen's duct (not gland) drains the parotid gland onto the buccal mucosa opposite the second molar. The sublingual gland is located within the floor of the mouth under the tongue. The submandibular gland lies beneath the mandible at the angle of the jaw.

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a."Are you aware of having any allergies?" b."Do you have an elevated temperature?" c."Have you had any symptoms of a cold?" d."Have you been having frequent nosebleeds?"

A With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a.Teeth appearing shorter b.Tongue that looks smoother in appearance c.Buccal mucosa that is beefy red in appearance d.Small, painless lump on the dorsum of the tongue

B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. The nurse recognizes that this is a result of: a.A problem with the patient's coagulation system. b.Increased vascularity in the upper respiratory tract as a result of the pregnancy. c.Increased susceptibility to colds and nasal irritation. d.Inappropriate use of nasal sprays.

B Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a.Inserting the speculum at least 3 cm into the vestibule b.Avoiding touching the nasal septum with the speculum c.Gently displacing the nose to the side that is being examined d.Keeping the speculum tip medial to avoid touching the floor of the nares

B The correct technique for using an otoscope is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

The primary purpose of the ciliated mucous membrane in the nose is to: a.Warm the inhaled air. b.Filter out dust and bacteria. c.Filter coarse particles from inhaled air. d.Facilitate the movement of air through the nares.

B The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a.No sensation b.Firm pressure c.Pain during palpation d.Pain sensation behind eyes

B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis).

During an oral examination of a 4-year-old Native-American child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a.This condition is a cleft palate and is common in Native Americans. b.A bifid uvula may occur in some Native-American groups. c.This condition is due to an injury and should be reported to the authorities. d.A bifid uvula is palatinus, which frequently occurs in Native Americans.

B Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some Native-American groups.

A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds areas of buccal mucosa that are raw and red with some bleeding, as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: a.Aphthous ulcers. b.Candidiasis. c.Leukoplakia. d.Koplik spots.

B Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in persons who are immunosuppressed. (See Table 16-4 for descriptions of the other lesions.)

In assessing the tonsils of a 30 year old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? a.Refer the patient to a throat specialist. b.No response is needed; this appearance is normal for the tonsils. c.Continue with the assessment, looking for any other abnormal findings. d.Obtain a throat culture on the patient for possible streptococcal (strep) infection.

B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a."While sitting up, place a cold compress over your nose." b."Sit up with your head tilted forward and pinch your nose." c."Just allow the bleeding to stop on its own, but don't blow your nose." d."Lie on your back with your head tilted back and pinch your nose."

B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a.Nutritional status b.When the patient first noticed the lesion c.Whether the patient has had a recent cold d.Whether the patient has had any recent exposure to sick animals

B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred

The nurse is teaching a health class to high-school boys. When discussing the topic of using smokeless tobacco (SLT), which of these statements are accurate? Select all that apply. a.One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. b.Using SLT has been associated with a greater risk of oral cancer than smoking. c.Pain is an early sign of oral cancer. d.Pain is rarely an early sign of oral cancer. e.Tooth decay is another risk of SLT because of the use of sugar as a sweetener. f.SLT is considered a healthy alternative to smoking.

B, D, E One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes. Pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, which promotes tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking.

The nurse is assessing a 3 year old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a.Refer to the physician for an antibiotic order. b.Have the mother bring the child back in 1 week. c.Perform an otoscopic examination of the left nares. d.Tell the mother that this drainage is normal for a child of this age.

C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a."We will need to get a biopsy to determine the cause." b."This is an overgrowth of hair and will go away in a few days." c."Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d."This is probably caused by the same bacteria you had in your lungs."

C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus.

During an assessment of a 26 year old at the clinic for "a spot on my lip I think is cancer," the nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? a.Tell the patient she needs to see a skin specialist. b.Discuss the benefits of having a biopsy performed on any unusual lesion. c.Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d.Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a.Attempt to suction again with a bulb syringe. b.Wait a few minutes, and try again once the infant stops crying. c.Recognize that this situation requires immediate intervention. d.Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a.Epistaxis b.Rhinorrhea c.Dysphagia d.Xerostomia

C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth.

When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a.Nasal polyps b.Acute sinusitis c.Allergic rhinitis d.Acute rhinitis

C Rhinorrhea, itching of the nose and eyes, and sneezing are present with allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. (See Table 16-1 for descriptions of the other conditions.)

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: a.Posterior epistaxis. b.Frontal sinusitis. c.Maxillary sinusitis. d.Nasal polyps.

C Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge.

During an oral assessment of a 30-year-old Black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a.Check the patient's hemoglobin for anemia. b.Assess for other signs of insufficient oxygen supply. c.Proceed with the assessment, knowing that this appearance is a normal finding. d.Ask if he has been exposed to an excessive amount of carbon monoxide.

C Some Blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. The nurse's best response would be: a."How many teeth did you have at this age?" b."All 20 deciduous teeth are expected to erupt by age 4 years." c."This is a normal number of teeth for an 18 month old." d."Normally, by age 2 years, 16 deciduous teeth are expected."

C The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally, all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

The projections in the nasal cavity that increase the surface area are called the: a.Meatus. b.Septum. c.Turbinates. d.Kiesselbach plexus.

C The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. During an inspection of his mouth, the nurse should look for: a.Swollen, red tonsils. b.Ulcerations on the hard palate. c.Bruising on the buccal mucosa or gums. d.Small yellow papules along the hard palate.

C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

A 10 year old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a.Tonsils 1+/1-4+ and pink; the same color as the oral mucosa b.Tonsils 2+/1-4+ with small plugs of white debris c.Tonsils 3+/1-4+ with large white spots d.Tonsils 3+/1-4+ with pale coloring

C With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a."These spots indicate an infection such as strep throat." b."These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c."This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d."These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky, white raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots.

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a."This area of irritation is caused from teething and is nothing to worry about." b."This finding is abnormal and should be evaluated by another health care provider." c."This area of irritation is the result of chronic drooling and should resolve within the next month or two." d."This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started bleeding. What would be an appropriate response by the nurse? a."Your condition is probably due to a vitamin C deficiency." b."I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c."You need to make an appointment with your dentist as soon as possible to have this checked." d."Swollen and bleeding gums can be caused by the change in hormonal balance in your system during pregnancy."

D Gum margins are red and swollen and easily bleed with gingivitis. A changing hormonal balance may cause this condition to occur in pregnancy and puberty.

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." The nurse's best response would be: a."You're right, drooling is usually a sign of the first tooth." b."It would be unusual for a 3 month old to be getting her first tooth." c."This could be the sign of a problem with the salivary glands." d."She is just starting to salivate and hasn't learned to swallow the saliva."

D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does.

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a.Sphenoid sinuses are full size at birth. b.Maxillary sinuses reach full size after puberty. c.Frontal sinuses are fairly well developed at birth. d.Maxillary and ethmoid sinuses are the only sinuses present at birth.

D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." The best response by the nurse would be: a."You're right. Bottles make very good pacifiers." b."Using a bottle as a pacifier is better for the teeth than thumb-sucking." c."It's okay to use a bottle as long as it contains milk and not juice." d."Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

The tissue that connects the tongue to the floor of the mouth is the: a.Uvula. b.Palate. c.Papillae. d.Frenulum.

D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be: a."You should never use over-the-counter nasal sprays because of the risk of addiction." b."You should try switching to another brand of medication to prevent this problem." c."Continuing to use this spray is important to keep your allergies under control." d."Using these nasal medications irritates the lining of the nose and may cause rebound swelling."

D The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a.Painful vesicle inside the cheek for 2 days b.Presence of moist, nontender Stensen's ducts c.Stippled gingival margins that snugly adhere to the teeth d.Ulceration on the side of the tongue with rolled edges

D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk of early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings.

A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the health history would be: a."Do you use a fluoride supplement?" b."Have you had tonsillitis in the last year?" c."At what age did you get your first tooth?" d."Have you noticed any dryness in your mouth?"

D Xerostomia (dry mouth) is a side effect of many drugs taken by older people, including antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, and bronchodilators.