Chapter 18 - Assessing Mouth, Throat, Nose, and Sinuses

During the health history of the nose and sinuses, a patient complains of having rhinorrhea. What question would the nurse ask to determine associated manifestations of this symptom? "In which side does it occur? "How long does it last?" "What color is the drainage?" "Are there any other symptoms?"

"Are there any other symptoms?"

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? "How many cigarettes do you smoke daily?" "Do you drink a lot of coffee or tea?" "Are you experiencing any tooth pain?" "Do you have trouble chewing your food?" TAKE ANOTHER QUIZ

"Are you experiencing any tooth pain?"

Tonsillitis grading scale

1+ Tonsils are visible. 2+ Tonsils are midway between tonsillar pillars and uvula. 3+ Tonsils touch the uvula. 4+ Tonsils touch each other.

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? 1+ 2+ 3+ 4+

4+

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? Normal, air-filled sinuses A large amount of exudate in the sinuses Obstruction of the nostril by a foreign object A perforated septum

A large amount of exudate in the sinuses

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom? Eye infection Oropharyngitis Acute otitis media Acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? acute bacterial sinusitis allergic rhinitis rhinitis medicamentosa epistaxis

Acute bacterial sinusitis

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

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 C D K

B12

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. Sloughing of papillae begins. Early jaundice can be detected. Lesions from loose dentures are found.

Cancers often occur

Before examining the mouth of an adult client, the nurse should first ask the client to leave dentures in place. don sterile gloves for the procedure. offer the client mouthwash. don clean gloves for the procedure. TAKE ANOTHER QUIZ

Don clean gloves for the procedure

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 Begin antibiotics immediately Correct client's dehydration Obtain a throat culture

Ensure a patient airway

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

Eye drops and sucking on hard candy may used to relieve dryness.

The frontal sinuses are the only ones readily accessible to clinical examination. T or F

False

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the mandible. frenulum. gums. soft palate. TAKE ANOTHER QUIZ

Frenulum

The client is experiencing red gums that are bleeding. The nurse identifies this as what? Gingivitis Torous palatinus Bifid uvula Ludwig's angina

Gingivitis

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: Angular cheilitis Herpes simplex Actinic cheilitis Angioedema

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 Dyspnea Dysphagia Alopecia

Hoarseness

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely? hypothyroidism gingivitis dysphagia apthous ulcers

Hypothyroidism

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? Rosenmuller's fossa Wharton's ducts Kiesselbach's plexus Stensen's duct

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 Petechiae Gingivitis Fordyce granules

Leukoplakia

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the ethmoidal sinuses. laryngeal sinuses. maxillary sinuses. sphenoidal sinuses. TAKE ANOTHER QUIZ

Maxillary sinuses

When inspecting a client's teeth, the nurse notes gingival hyperplasia. What should the nurse assess to determine the cause for this finding? medications use of tobacco oral fluid intake last respiratory illness TAKE ANOTHER QUIZ

Medications

The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion? Finish the bottle of nasal spray to clear the infection effectively. Nasal spray can be shared between family members only. Administer the nasal spray in a prone position. Overuse of nasal spray may cause rebound congestion.

Overuse of nasal spray may cause rebound congestion

The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply. Patency of the sinus ostia Normal cilia function Normal quality and quantity of the mucus Deep cervical and retropharyngeal nodes An abundant lymph supply

Patency of the sinus ostia Normal quality and quantity of the mucus Normal cilia function

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

Put the medication underneath your tongue

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the teeth. gums. muscles. soft palate.

Soft palate

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? Cool and dry expired air Move mucus to the back of the throat Moisten and filter expired air Warm and humidify inspired air

Warm and humidify inspired air

The rich blood supply of the nose serves to help propel moist air to the body. propel debris to the throat. filter large particles from the air. warm the inspired air.

Warm the inspired air

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? gloves penlight tongue depressor speculum tuning fork

gloves penlight tongue depressor