Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses PREPU

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? a. Dysphagia b. Right ptosis c. Facial weakness d. Weak gait

a. Dysphagia

The client has experienced a stroke and has dysphagia. The nurse knows this is what? A. Painful swallowing B. Difficulty swallowing C. Lack of gag reflex D. Difficulty talking

B. Difficulty swallowing

The nurse prepares material about oropharyngeal cancer for a community health fair. What should the nurse include as actions to prevent the development of this disease? Select all that apply. - Limit sun exposure - Eat fresh fruits and vegetables - Avoid smoking - Avoid excessive alcohol use - Practice daily oral hygiene

- Avoid smoking - Avoid excessive alcohol use - Eat fresh fruits and vegetables

Which statement regarding oral cancer is correct? Select all that apply. - Smoking is a risk factor for oral cancer. - Risk factors for oral cancer includes oral sex. - African Americans have a higher incidence of oral cancer. - Oral cancer occurs more frequently in females. - Oral cancer occurs more frequently in males.

- Oral cancer occurs more frequently in males. - Risk factors for oral cancer includes oral sex. - Smoking is a risk factor for oral cancer.

The nurse assesses the frontal sinus where? A. Above the eyes B. Below the eyes C. Above jaw D. Below jaw

A. Above the eyes

The Kiesselbach plexus is the most common site for what? A. Anterior nosebleeds B. Posterior nosebleeds C. Sinusitis D. Infections

A. Anterior nosebleeds

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: A. Cancers often occur. B. Sloughing of papillae begins. C. Lesions from loose dentures are found. D. Early jaundice can be detected.

A. Cancers often occur.

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? A. Ensure a patent airway B. Obtain a throat culture C. Correct client's dehydration D. Begin antibiotics immediately

A. Ensure a patent airway

You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? A. Hoarseness B. Dysphagia C. Alopecia D. Dyspnea

A. Hoarseness

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? A. How to reduce periodontal disease B. How to safely put an infant to bed with a bottle C. Beginning dental care in children at age 5 D. How oral cancer is diagnosed

A. How to reduce periodontal disease

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? A. Receding and ischemic gums B. Bifid uvula C. Brown spots on the chewing surface of teeth D. Enlarged palatine tonsils

A. Receding and ischemic gums

A client who is semiconscious is brought to the emergency department of a health care facility after being rescued from a fire. Which finding of the lips supports the diagnosis of carbon monoxide poisoning? A. Reddish B. Cyanotic C. Swelling D. Pallor

A. Reddish

The submandibular glands open under the tongue through openings called A. Wharton ducts. B. parasinal ducts. C. lacrimonasal ducts. D. Stensen ducts.

A. Wharton ducts.

A client is being seen in the clinic after several incidences of aspirating food and drink due to difficulty swallowing. What term would the nurse use to document these findings? A. dysphagia B. malocclusion C. gastroesophageal reflux disease (GERD) D. odynophagia

A. dysphagia

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the A. maxillary sinuses. B. laryngeal sinuses. C. ethmoidal sinuses. D. sphenoidal sinuses.

A. maxillary sinuses.

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 A. touching each other. B. visible upon inspection. C. touching the uvula. D. midway between the tonsillar pillars and uvula.

A. touching each other.

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

A. warm the inspired air.

A nurse assesses a client who is reporting a sore throat and difficult, painful swallowing. The nurse observes that the client's tonsils are touching each other. What ranking (grade scale) should the nurse document for tonsillitis? A. 3+ B. 4+ C. 1+ D. 2+

B. 4+

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? A. End-stage liver disease B. Diabetic ketoacidosis C. Respiratory infection D. Small-bowel obstruction

B. Diabetic ketoacidosis

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? A. Buccal mucosa across from the second upper molars B. Either side of the frenulum on the floor of the mouth C. Posterior aspect of the tongue bilaterally D. Right side of the frenulum at the base of the gums

B. Either side of the frenulum on the floor of the mouth

The frontal sinuses are the only ones readily accessible to clinical examination. A. True B. False

B. False

A client comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? A. Thompson plexus B. Kiesselbach plexus C. Sinuses D. Wharton ducts

B. Kiesselbach plexus

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? A. Rosenmuller fossa B. Kiesselbach plexus C. Ala D. Columella

B. Kiesselbach plexus

The nurse is caring for a client admitted to the medical surgical unit with neck tenderness, drooling, and dysphagia. In reviewing the orders from the health care provider (see above), which order should the nurse question? A. acetaminophen 10-15mg/kg IV q 4-6 hours PRN for pain or fever B. regular diet as tolerated C. strict intake and output D. complete blood count with differential

B. regular diet as tolerated

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? A. 1+ B. 2+ C. 4+ D. 3+

C. 4+

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? A. Heavy alcohol use B. Chewing betel nuts C. Asthma D. Exposure to the sun

C. Asthma

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? A. Cranial nerve X (vagus) B. Cranial nerve I (olfactory) C. Cranial nerve XII (hypoglossal) D. Cranial nerve VII (facial)

C. Cranial nerve XII (hypoglossal)

The nurse understand the molars are responsible for what? A. Support B. Biting C. Grinding D. Cutting

C. Grinding

What is the common channel for the respiratory and digestive systems? A. Nares B. Frenulum C. Oropharynx D. Sinuses

C. Oropharynx

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? A. Bluish gray, swollen, with watery exudate B. Dark pink, moist, & free of discharge C. Red, swollen, with purulent discharge D. Pale pink, swollen, with watery exudate

C. Red, swollen, with purulent discharge

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? A. Tilting the head backwards, with the neck flexed B. Prone, with arms relaxed at the sides C. Sitting with the head erect and at the eye level of the nurse D. Semi-recumbent position, with the chin lifted

C. Sitting with the head erect and at the eye level of the nurse

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? A. Torus palatinus B. Diphtheria C. Thrush D. Kaposi's sarcoma

C. Thrush

The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client? A. Yeast infection B. Recent use of antibiotics C. Vitamin deficiency D. Cranial nerve XII damage

C. Vitamin deficiency

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 A. trauma to the nasal passages. B. too much smoking. C. an upper respiratory infection. D. chronic allergies.

C. an upper respiratory infection.

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? A. Reddish B. Pallor C. Swelling D. Cyanotic

D. Cyanotic

A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client? A. Ethmoidal B. Sphenoidal C. Frontal D. Maxillary

D. Maxillary

Which characteristic of the gums should a nurse expect to assess in a client who is healthy? A. Enlarged, reddened B. A grey-white line C. Red, bleeding D. Pink, moist, firm

D. Pink, moist, firm

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the gums and teeth? A. Use a square gauze pad to hold the client's tongue to each side. B. Ask the client to stick the tongue out between the lips. C. Use a penlight and tongue depressor to retract the lips. D. Put on gloves and retract the client's lips and cheeks.

D. Put on gloves and retract the client's lips and cheeks.

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: A. Ala nasi, vestibule, and ethmoid sinuses B. Turbinates, ethmoid sinuses, and nasal passages C. Ala nasi, turbinates, and nasopharynx D. Vestibule, nasal passages, and nasopharynx

D. Vestibule, nasal passages, and nasopharynx

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? A. rhinitis medicamentosa B. epistaxis C. allergic rhinitis D. acute bacterial sinusitis

D. acute bacterial sinusitis

A client comes to the clinic reporting pain, tenderness, swelling, and pressure around the eyes, cheeks, nose, and forehead for the past 12 weeks. Based on these findings, which of the following disorders is the client most likely experiencing? A. acute rhinitis B. deviated septum C. epistaxis D. chronic sinusitis

D. chronic sinusitis

A client reports having had difficulty breathing through their right nostril for years. The client denies any other symptoms except for unrestful sleep. The nurse suspects that the client may have which of the following conditions? A. rhinorrhea B. congestion C. acute sinusitis D. deviated septum

D. deviated septum

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

D. soft palate.

The health care provider documented that a client is experiencing edema of the left maxillary sinus. Where on the diagram provided should the nurse expect to observe this swelling?

LEFT SIDE SINUS BY THE NOSE

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? a. B12 b. C c. D d. K

a. B12

A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect? a. Posteriorly near tonsils b. Both sides c. Frenulum d. At the very tip

b. Both sides