Chapter 15
A client's spouse reports to the nurse that the client sometimes stops breathing during sleep and asks if this is serious. What is the best response by the nurse? "Your spouse has sleep apnea, which can cause problems with blood pressure." "Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." "Your spouse is suffering from a normal condition of aging known as sleep apnea." "Everyone experiences periods of apnea when they are in deep REM sleep."
"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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 385. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 385
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? 2+ 3+ 4+ 1+
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+. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 392. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 392
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 that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? Self-Care Deficit Hopelessness Acute Pain
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 neurologic or neuromuscular function. There is no criterion to confirm that this client cannot maintain health maintenance because this is an acute problem. No data exist to confirm the nursing diagnoses of Self-Care Deficit or Hopelessness. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
When assessing a client, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a client from what background? Pacific Islander African American Asian American Native American
African American Explanation: In dark-skinned clients, the gums are more deeply colored; a brownish ridge is often found along the gum line. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 394. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to? Crusting Traverse ridge Angular cheilitis Koplik's spots
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 394. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client? Chewing betel nuts Exposure to the sun Asthma Heavy alcohol use
Asthma Explanation: This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke. The other answers listed—chewing betel nuts, exposure to the sun, and heavy alcohol use—are all risk factors for oropharyngeal cancer, but not for sinusitis. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 401. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 401
The nurse is caring for a client in the emergency department for epistaxis. What information should the nurse include in client discharge teaching as a way to prevent epistaxis? Use a dehumidifier. Use a tissue when blowing the nose. Avoid picking the nose. Keep the nasal passages clear.
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 386-400. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 386-400
A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin? K C B12 D
B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 394. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
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? Heavy alcohol use Chewing betel nuts Smoking cigarettes 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 379-387. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379-387
On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment? History of abuse Chronic nose picking Chronic allergies Mucosal polyps
Chronic allergies Explanation: A line across the tip of the nose just above 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
The nurse identifies this as trapping debris and propelling it toward the nasopharynx. Cilia Turbinates Columella 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. The columella divides the nostrils. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 374. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 374
Which genetic disorder would the nurse ask about when conducting a family history regarding upper respiratory illness? Churg Strauss syndrome Wegener granulomatosis Cystic fibrosis Sjogren syndrome
Cystic fibrosis is an autosomal recessive genetic disorder characterized by thick, sticky mucus in the lungs, intestines, liver, and pancreas. Sjogren syndrome is an autoimmune disorder resulting in decreased production of tears and saliva. Wegener granulomatosis is an autoimmune disorder characterized by inflammation of blood vessels, causing decreased blood flow. Churg Strauss syndrome is an autoimmune disorder characterized by inflammation and necrosis of blood vessels. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 384. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 384
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? Posterior aspect of the tongue bilaterally Buccal mucosa across from the second upper molars Either side of the frenulum on the floor of the mouth Right side of the frenulum at the base of the gums
Either side of the frenulum on the floor of the mouth Explanation: The nurse should inspect the Wharton's ducts on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right side of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate sites to inspect for salivary ducts. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 377-389. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 377-389
A client diagnosed with Sjogren syndrome should be given which instructions? Taking mucus thinning medication can relieve symptoms. Eye drops and sucking on hard candy may used to relieve dryness. Condom use can reduce the risk of transmission. Blood pressure should be checked frequently.
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information? Tonsillar enlargement History of dysphagia Frequency of nosebleeds History of allergies
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 383-384. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 383-384
The nurse is assessing a client with chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? "Would you say that you eat a balanced diet?" "How often do you use over-the-counter nasal sprays?" "How many drinks of alcohol do you have in a typical day?" "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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 383-400. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 383-400
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? Reassure the mother that this is common in children Assess for allergies to antibiotic Inspect the nostrils with an otoscope Have the child blow the nose to assess drainage
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 400-402. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 400-402
An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? Kiesselbach plexus Rosenmuller fossa Columella Ala
Kiesselbach plexus Explanation: Kiesselbach plexus is the most common site of epistaxis. Rosenmuller fossa is the most common site of nasopharyngeal cancer. The midline columella divides the oval nares (nostrils), which are openings that lead into the internal nose and are lined with the skin and the ciliated mucosa. The anterior slope of the nose is the dorsum, which ends inferiorly at the tip and laterally at the ala. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 375-386. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 375-386
A client comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? Kiesselbach plexus Thompson plexus Wharton ducts Sinuses
Kiesselbach plexus Explanation: The most common site of nasal bleeding is the Kiesselbach plexus on the anterior septum. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 375. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 375
After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw? Sphenoidal Maxillary Frontal Ethmoidal
Maxillary Explanation: The maxillary sinuses are located in the upper jaw. The frontal sinuses are located above the eyes. The ethmoidal and sphenoidal sinuses are located deeper in the skull and not accessible for examination. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 378. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 378
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Encrusted mucous membranes Hardened secretions Erosion of the trachea Noisy breathing
Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat. Add a Note
What is the common channel for the respiratory and digestive systems? Oropharynx Frenulum Sinuses Nares SUBMIT ANSWER
Oropharynx Explanation: The oropharynx is the common channel for the respiratory and digestive systems. The frenulum is part of the tongue. The nares are part of the nose. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 379. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion? Overuse of nasal spray may cause rebound congestion. Nasal spray can be shared between family members only. Administer the nasal spray in a prone position. Finish the bottle of nasal spray to clear the infection effectively.
Overuse of nasal spray may cause rebound congestion. Explanation: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximum distribution of the spray. Only the client should use the bottle. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 383-384. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 383-384
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? Dull sounds Pain on percussion Resonance on percussion Tympanic 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 387-399. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 387-399
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? Paralysis of cranial nerve X (vagus) Native American heritage Cerebrovascular accident Tonsil infection
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 390. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 390
A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Prone, with arms relaxed at the sides Sitting with the head erect and at the eye level of the nurse Tilting the head backwards, with the neck flexed Semi-recumbent position, with the chin lifted SUBMIT ANSWER
Sitting with the head erect and at the eye level of the nurse Explanation: The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination and palpation of the sinuses more difficult for the examiner. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 388. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 388
The client 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 client has? Strep throat Pharyngitis Leukoplakia 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 392-405. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 392-405
The nurse is assessing the client's vagus nerve (CN X). Which nursing action would the nurse perform? The nurse inspects the buccal mucosa and tongue. The nurse asks the client to identify common scents. The nurse instructs the older adult to say "ah." The nurse palpates the maxillary sinus areas.
The nurse instructs the older adult to say "ah." Explanation: 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 would ask the client to identify common scents to assess for a loss of smell. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 390. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 390
Upon inspection of a client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding? Enlargement of the tonsils with infection is a common cause This is often a normal finding in the Native American population Paralysis of cranial nerve X (vagus) nerve is likely to be present The client should be assessed for a cerebrovascular accident (CVA)
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 379. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
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? Kaposi's sarcoma Leukoplakia Torus palatinus Thrush (candidiasis)
Torus palatinus Explanation: Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 379. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Warm and humidify inspired air Moisten and filter expired air Cool and dry expired air Move mucus to the back of the throat
Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucous in the nasal cavities and filter the inspired air. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 374. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 374
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? VI XII VIII III
XII Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve. The third cranial nerve is involved with eye muscle movement. The sixth cranial nerve is involved with lateral eye movement. The eighth cranial nerve is involved with hearing and equilibrium Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
The nurse notes a brown hairy coating on the tongue when assessing the oral cavity of the client. Which medication would the nurse suspect as the causative agent when reviewing the client's medications? albendazole (Albenza) amoxicillin (Amoxil) ketoconazole (Nizoral) acyclovir (Zovirax)
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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 407. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 407
The client reports two nosebleeds in the past week. Which medication taken by the client would the nurse suspect is contributing to the nosebleeds? omeprazole (Prilosec) levothyroxine (Synthroid) clopidogrel (Plavix) lithium (Eskalith)
clopidogrel (Plavix) Explanation: Anticoagulants, such as clopidogrel (Plavix), may predispose clients to nosebleeds or exacerbate bleeding. Nosebleeds are not a side effect of omeprazole (Prilosec), levothyroxine (Synthroid), or lithium (Eskalith). Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 383-400. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 383-400
Before examining the mouth of an adult client, the nurse should first don sterile gloves for the procedure. offer the client mouthwash. don clean gloves for the procedure. ask the client to leave dentures in place.
don clean gloves for the procedure. Explanation: Before touching any mucous membranes the nurse should apply gloves. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 388. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 388
The nurse is assessing the client with gastroesophageal reflex disease. Which clinical manifestations would the nurse include in the history? Select all that apply. cough anosmia halitosis voice changes dysphagia
dysphagia voice changes cough 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. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 386. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 386
The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the sphenoidal sinuses. maxillary sinuses. laryngeal sinuses. ethmoidal sinuses.
maxillary sinuses. Explanation: The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 393. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 393
