Chapter 18- Assessing mouth throat nose and sinuses
A patient is having their tonsils removed. The patient asks the nurse what function the tonsils serve. Which of the following would be the most accurate response?
"The tonsils help to guard the body from invasions of organisms."
Upon inspection of a Native American client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding?
This is often a normal finding in the Native American population
During an examination of the oral cavity, which technique by the nurse is most likely to improve visualization of the buccal mucosa?
Use a penlight and tongue depressor to retract the lips
An extension of the soft palate of the mouth, which hangs in the posterior midline of the oropharynx, is the
Uvula
A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?
Vitamin B12 deficiency
During the nursing assessment, the nurse identifies the client has a smooth, glossy tongue. The nurse understands this is caused by what?
Vitamin B12 deficiency
The rich blood supply of the nose serves to
Warm the inspired air
While a nurse is examining his sinuses, a 10-year-old boy asks the nurse what the sinuses are for. Which of the following should the nurse mention as functions of the sinuses? Select all that apply.
-Decrease the weight of the skull -Act as resonance chambers during speech
Upon assessment of the tonsils, the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?
1+
You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer?
Warm the inspired air
The nurse assesses the frontal sinus where?
Above the eyes
The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to
An upper respiratory infection
The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for
Aspiration
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?
B12
What lines the cheeks?
Buccal mucosa
The nurse identifies this as trapping debris and propelling it toward the nasopharynx.
Cilia
The submandibular glands open under the tongue through openings called
Wharton ducts
A nurse is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client?
Cranial nerve XII (hypoglossal)
A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client?
Cyanotic
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?
End stage liver disease
A client diagnosed with Sjogren syndrome should be given which instructions?
Eye drops and sucking on hard candy may used to relieve dryness
The frontal sinuses are the only ones readily accessible to clinical examination.
False
The nurse understand the molars are responsible for what?
Grinding
A patient presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The patient describes these as painful. The nurse suspects what condition?
Herpes simplex
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem?
Herpes simplex
A mother brings her 6-month-old child to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the client's mouth?
White coated tongue
An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis?
Kiesselbach plexus
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?
Laryngeal cancer
What is the common channel for the respiratory and digestive systems?
Oropharynx
During an examination of the oral cavity, which technique by the nurse is appropriate to examine the gums and teeth?
Put on gloves and retract the client's lips and cheeks
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?
Red, bleeding
A client's nasal mucosa is pale reddish-blue. What should the nurse ask the client to validate this finding?
"Do you sneeze a lot when around fresh cut grass or pollen?"
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?
Asthma
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?
Either side of the frenulum on the floor of the mouth
During examination 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?
Either side of the frenulum on the floor of the mouth
When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of rhinorrhea. Which question should the nurse ask to determine associated manifestations of this symptom?
"Have you had a sore throat?"
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?
A large amount of exudate in the sinuses
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?
Acute pain
When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:
Cancers often occur
A nurse is conducting an admission assessment on an older adult client with an intractable oral infection. The client tells the nurse that he cannot smell things as well as he once could. What should the nurse do?
Chart the information in the medical record
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?
Chewing betel nuts
The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to
Depress the tongue blade slightly off center
A client is brought to the emergency department in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process?
Diabetic ketoacidosis
The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?
Diets low in fruits and vegetables are a possible risk factor for oral cancer
The client has experienced a stroke and has dysphagia. The nurse knows this is what?
Difficulty swallowing
Before examining the mouth of an adult client, the nurse should first
Don clean gloves for the procedure
A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?
Dysphagia
A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client?
Ensure a patent airway
During the physical examination of the mouth, the nurse identifies vesicular eruptions along the patient's lips and surrounding skin. The nurse would document this finding as being:
Herpes simplex
You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
Hoarseness
You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
Hoarsness
A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation?
How to reduce periodontal disease
A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?
Impaired swallowing
A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?
Inspect the nostrils with an otoscope
A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?
Kiesselbach's plexus
During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record?
Leukoplakia
An older patient who wears dentures complains of having sore gums. What can the nurse instruct the patient to help with this problem?
Massage the gums everyday
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
Which instructions should the nurse provide to the client taking a sublingual medication?
Put the medication underneath your tongue
Which of the following principles should guide the nurse's assessment of clients' oral health?
Poor oral health has both physical and psychosocial implications
Which technique should the nurse use to examine the sinuses of a client with a sinus infection?
Press up on the brow on each side of the nose to palpate the frontal sinuses
A nurse is assessing a client who was stung in the face by a bee. Which finding about the lips supports the diagnosis of local allergic reaction?
Swelling
A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection?
Red, swollen, with purulent discharge
A client who is semi-conscious is brought to the emergency unit of a health care facility after being rescued from a fire. Which finding of the lips supports the diagnosis of carbon monoxide poisoning?
Reddish
A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristic of the client's symptom is the nurse assessing?
Relieving factors
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?
Respiratory infection
A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client?
Rinse mouth with anti fungal medications as prescribed
A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?
Sit with the head erect and at the eye level of the nurse
A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses?
Sitting with the head erect and at the eye level of the nurse
On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process?
Small bowel obstruction
The roof of the oral cavity of the mouth is formed by the anterior hard palate and the
Soft palate
An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explain to the client that grinding the teeth may be a sign of
Stress and anxiety
A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect?
Thrush
An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are
Touching each other
The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique?
Vagal nerve function
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:
Vestibule, nasal passages and nasopharynx
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 comprised 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
