chapter 15

3) The nurse is preparing to assess the ventral surface of the tongue. Which should the nurse anticipate to find? 1. Papillae. 2. Parotid salivary glands. 3. Smooth vascular tissue. 4. Frenulum.

3. Smooth vascular tissue.

4) The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract? 1. Olfactory cells. 2. Columella. 3. Turbinates. 4. Nares.

3. Turbinates.

33) The nurse observes white patches on the tympanic membrane. Which question should the nurse ask the client that is most relevant to the finding? 1. "Do you have a history of ear infections?" 2. "Have you experienced any recent hearing loss?" 3. "Are you currently on any medication?" 4. "Are you experiencing any pain in your ears?"

1. "Do you have a history of ear infections?"

2) A client with recent cerebrovascular accident (CVA) is no longer able to smell. Which cranial nerve assessment should the nurse anticipate to include in the documentation? 1. Cranial nerve I. 2. Cranial nerve XII. 3. Cranial nerve VIII. 4. Cranial nerve VII.

1. Cranial nerve I

13) The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Select all that apply. 1. Irrigating with warm mineral oil, peroxide, and flushing with warm water. 2. Inserting a sharp instrument to break up the ear wax. 3. Irrigating with a cold solution. 4. Inserting a cerumen spoon to remove the wax. 5. Irrigating with warm sudsy water.

1. Irrigating with warm mineral oil, peroxide, and flushing with warm water. 4. Inserting a cerumen spoon to remove the wax.

25) An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client? 1. Presbycusis. 2. Mastoiditis. 3. Otitis media. 4. Otitis externa.

1. Presbycusis.

17) The emergency department triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. Which interpretation of the assessment data by the nurse is the most appropriate? 1. Produced by severe nasal inflammation or obstruction. 2. Normal for a child. 3. A result of chronic allergies. 4. A result of sinusitis.

1. Produced by severe nasal inflammation or obstruction.

12) The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. Which action by the nurse is appropriate in this situation? 1. Pull the pinna up and back and then reinsert the otoscope. 2. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 4. Pull the pinna down and back and then reinsert the otoscope.

1. Pull the pinna up and back and then reinsert the otoscope.

20) A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Select all that apply. 1. Request information from the client regarding increased propensity for bruising or bleeding. 2. Assess the tonsils for redness or swelling 3. Obtain a blood pressure. 4. Check for deviated septum. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.

1. Request information from the client regarding increased propensity for bruising or bleeding. 3. Obtain a blood pressure. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.

23) The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. Based on this data, which does the nurse suspect? 1. Rhinitis. 2. Perforated septum. 3. Previous epistaxis. 4. Nasal polyps.

1. Rhinitis.

8) The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? Select all that apply. 1. Streptomycin. 2. Steroid inhalers. 3. Aspirin. 4. Neomycin. 5. Acetaminophen.

1. Streptomycin. 3. Aspirin. 4. Neomycin.

14) During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? Select all that apply. 1. The nurse notes that the nasal septum has perforated. 2. Temporomandibular joint pain when the client opens and closes the mouth. 3. The septum is noted to be very pale in color. 4. Yeast infection of nasal mucosa and in mouth. 5. Difficulty swallowing water.

1. The nurse notes that the nasal septum has perforated. 3. The septum is noted to be very pale in color.

30) The nurse is preparing to review the secondary sources of data for a client that has experienced a hearing loss. Which diagnostic testing should the nurse anticipate may have been performed? Select all that apply. 1. X-ray. 2. Computed tomography. 3. Electronystagmography. 4. Audiometric screening. 5. Auditory screening.

1. X-ray. 3. Electronystagmography. 4. Audiometric screening. 5. Auditory screening.

26) The nurse notes there is no red glow when transilluminating the maxillary sinuses. Which initial question should the nurse ask the client? 1. "Have you experienced any nasal drainage?" 2. "Do you have any allergies?" 3. "Do you take any routine sinus medication?" 4. "Are you experiencing any sinus pain?"

2. "Do you have any allergies?"

28) The nurse educator is teaching a group of students about cultural differences to consider when conducting an ear, nose, and throat assessment. Which statement by a nursing student indicates appropriate understanding of the information presented? 1. "Asians are more likely to experience greater difficulty with otitis media than people from other cultures." 2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark." 3. "Asians have a higher risk of having issues associated with cleft lips and cleft palates." 4. "Asians have a high incidence of tooth decay."

2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark."

18) A client presents in the healthcare provider's office with complaints of headache and malaise. During the assessment, the nurse notes the client is experiencing severe pain when palpating behind the ears. Based on this data, which diagnosis does the nurse anticipate? 1. Sinusitis. 2. Mastoiditis. 3. Chronic allergies. 4. Anemia.

2. Mastoiditis.

1) A client asks the nurse what part of the ears becomes blocked with pressure when they travel on an airplane. Which structure of the ear should the nurse be prepared to discuss? 1. Tympanic membrane. 2. Ossicles. 3. Cochlea. 4. Eustachian tube.

2. Ossicles.

21) The nurse is examining a toddler client. The toddler has a fever and the nurse notes the ear canal is red and swollen and the presence of purulent drainage. Based on this assessment data, which diagnosis does the nurse anticipate? 1. Otitis media. 2. Otitis externa. 3. Hemotympanum. 4. Tophi.

2. Otitis externa.

16) A young mother brings an infant to the pediatric clinic. The infant has had a fever and is pulling at the left ear. Based on this data, which disorder does the nurse suspect? 1. Sinusitis. 2. Otitis media. 3. Tonsillitis. 4. Otitis externa.

2. Otitis media.

9) The client has developed anosmia. The nurse educates the client about the possible causes of this condition. Which topics are appropriate for the nurse to include in the teaching session with the client? Select all that apply. 1. Commonly associated with gingivitis. 2. Possibly linked to heredity. 3. Related to a diet deficient in zinc. 4. An indicator of a neurological problem. 5. Caused by dental caries.

2. Possibly linked to heredity. 3. Related to a diet deficient in zinc. 4. An indicator of a neurological problem.

11) The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect? 1. Acute otitis media. 2. Recent trauma. 3. Blocked eustachian tubes. 4. History of frequent middle ear infections.

2. Recent trauma.

10) The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action? 1. Requesting information from the client regarding any chronic allergies. 2. Testing the drainage for glucose. 3. Asking the client if there have been recent middle ear infections. 4. Irrigating the ear with warm mineral oil or peroxide and flushing with warm water.

2. Testing the drainage for glucose.

29) The nurse is assessing several children in a pediatric clinic. Which child is experiencing a delay in the eruption of decidual teeth? 1. The 6-month-old infant that has one deciduous tooth. 2. The 18-month-old child that has 6 deciduous teeth. 3. The 4-month-old infant that has no deciduous teeth. 4. The 24-month-old child that does not have their second molars.

2. The 18-month-old child that has 6 deciduous teeth.

24) The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data? 1. "Have you recently been ill?" 2. "Do you chew tobacco?" 3. "Have you recently taken antibiotics?" 4. "Do you have a history of oral infections?"

3. "Have you recently taken antibiotics?"

22) The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen. 4. Provide a warm drink.

3. Administer oxygen.

27) The nurse observes that the Wharton's ducts are painful, reddened, and swollen. Which additional assessment finding should the nurse anticipate? 1. Bleeding gums. 2. Lesions. 3. Dry mouth. 4. Leukoplakia.

3. Dry mouth.

5) Which structure attaches the tongue to the floor of the mouth? 1. Hard palate. 2. Papillae. 3. Frenulum. 4. Alveoli sockets.

3. Frenulum.

6) The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client? Select all that apply. 1. Increasing risk of developing otitis externa. 2. Developing tophi along the outer rim of the ears. 3. Perforating the tympanic membrane. 4. Needing tympanostomy tubes. 5. Impacting cerumen.

3. Perforating the tympanic membrane. 5. Impacting cerumen.

31) The nurse conducting the Rinne test notes that the client hears the bone conduction sound longer than the air conduction sound. Which should the nurse anticipate documenting? 1. Possible conductive hearing loss. 2. No hearing loss. 3. Sensorineural hearing loss. 4. Mixed hearing loss.

3. Sensorineural hearing loss.

32) The educator is reviewing the Rinne test with a new nurse. Which statement by the nurse indicates an understanding of the test? 1. "This test requires the use of an otoscope." 2. "The test is performed by whispering statements a few feet away from the client." 3. "The test is used to determine if a client hears sound in one ear better than the other." 4. "This test compares air and bone conduction of sound using a tuning fork."

4. "This test compares air and bone conduction of sound using a tuning fork."

15) The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which interventions will the nurse implement? 1. Allow the client to walk independently. 2. Obtain an order for a catheter. 3. Limit fluid intake. 4. Obtain a bedside commode.

4. Obtain a bedside commode.

19) The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include? 1. Bleeding and inflamed gums. 2. Smooth and shiny tongue. 3. Red, swollen tonsils. 4. Ulcerations on the lip or under the tongue.

4. Ulcerations on the lip or under the tongue.

7) A client tells the nurse they are experiencing pain and noticed some drainage from their left ear. Which objective finding indicates the client may have developed acute otitis media? 1.Reddened ear canal. 2. Clear watery drainage. 3.Mucus-like drainage. 4. Yellowish-reddish drainage.

4. Yellowish-reddish drainage.