Exam 3 - 18 & 24

Ankylosing spondylitis

A nurse inspects a flattened lumbar curvature in a client. Which of the following conditions should the nurse most suspect in this client?

temporomandibular joint

The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further?

Above the eyes

The nurse assesses the frontal sinus where?

3+

The nurse examines the pharynx of a patient and records that the tonsils are touching the uvula. The nurse would grade the tonsils as

- "Do you drink a lot of coffee or tea?" - "How many cigarettes do you smoke daily?"

A nurse inspects the gums and teeth of a client and notices a brownish tint to the teeth. What questions should the nurse ask the client to determine the cause of this finding? Select all that apply.

"Are you experiencing any tooth pain?"

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?

A grey-white line

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client?

- swelling - tenderness - redness - warmth

A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

Toes point out

A nurse is inspecting a client's gait. Which of the following would indicate an abnormal finding?

Kiesselbach's plexus

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?

Compare this finding to the range of motion to the right side

A nurse notices that a client has decreased range of motion with lateral bending of the cervical spine to the left side. What should the nurse do next in relation to this finding?

Straight leg raise test

A 32-year-old warehouse worker presents for evaluation of low back pain. He notes a sudden onset of pain after lifting a heavier-than-usual set of boxes. He also states that he has numbness and tingling in the left leg. What test should the nurse perform to assess for a herniated disc?

Sitting 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?

Inspect the nostrils with an otoscope

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?

Asthma

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?

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

A client diagnosed with Sjogren syndrome should be given which instructions?

Ensure a patent airway

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 large amount of exudate in the sinuses

A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client?

C7 and T1 spinous processes prominent. Paravertebral, sternocleidomastoid, and trapezius muscles fully developed, symmetrical, and nontender

A nurse has just finished assessing a client's spine and neck muscles. How would the nurse document normal findings?

- Frequent pipe smoking - Heavy use of alcohol

A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client?

flexion

A client has osteoarthritis of the elbow. Which assessment approach should the nurse expect to be impacted by this health problem?

Impaired physical mobility related to reduced strength and ROM

A client has rheumatoid arthritis most prominent in the hands, where the client has decreased range of motion (ROM), pain, and tenderness. What is an appropriate nursing diagnosis for this client?

Check for a pulse, color, temperature, and capillary refill.

A client presents to the emergency department after falling off a ladder while doing some outside painting at home. The client's ankle appears swollen, out of alignment, and is painful to touch. What is the nurse's first action?

Acute Pain

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?

Cervical strain

A client presents to the health care clinic with reports of onset of neck pain 3 days ago. The nurse recognizes that the most common cause of neck pain is what condition?

Impaired Physical Mobility

A client presents to the health care clinic with reports of pain in the hands and right wrist. Additional history reveals that the client is a factory worker who spends all day performing the same repetitive task. The nurse performs Phalen's test and Tinel's test with positive results. The hand grips are unequal, with the right weaker than the left. What nursing diagnosis can the nurse confirm from this data?

Both sides

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?

anterior nose area

A client reports having occasional nosebleeds. Where should the nurse focus when assessing this client?

Acute bacterial rhinosinusitis

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?

flex the knee and hip while in a supine position.

A client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is "locking up." The nurse should perform the McMurray test by asking the client to

arthritis.

A client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. The nurse should assess the client further for signs and symptoms of

Ask the client to raise the leg to the point of pain and then dorsiflex the foot

A client visits the health care facility with reports of lumbar back pain that radiates down the back. The nurse performs the straight leg test to determine the origin of the pain. Which techniques should the nurse use to perform this test?

Rinse mouth with antifungal medication as prescribed.

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?

Dorsiflexion and plantar flexion

A college age athlete presents to the clinic with pain in the tibiotalar joint. It is a hinge joint limited to flexion and extension. The terms used to describe these movements are what?

osteoporosis

A female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. The nurse should instruct the client that she is at a higher risk for

Dysphagia

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern?

4+

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+

A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

- "Does your child have painless bruising?" - "Does your child pick his nose?" - "Is your child taking any medications?"

A parent reports her preschool-aged child has been having epistaxis every 2 to 3 days for the past month. Which questions should the nurse ask to determine the possible causes? Select all that apply.

Kiesselbach plexus

A patient comes to the clinic and reports nosebleeds. What area of the nose is thebleeding most likely coming from?

Vitamin B12 deficiency

A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?

Gouty arthritis

A patient presents at the clinic with an enlarged, swollen, hot, and red metatarsophalangeal joint and bursa of the great toe. What medical diagnosis would the nurse suspect?

How to reduce periodontal disease

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 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?

Torus palatinus

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?

- Asked the client to rock the jaw laterally - Asked the client to open and close the mouth - Asked the client to jut the jaw forward

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? (Select all that apply.)

Massage the gums daily.

An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem?

hip joint.

Articulation between the head of the femur and the acetabulum is in the

don clean gloves for the procedure.

Before examining the mouth of an adult client, the nurse should first

Either side of the frenulum on the floor of the mouth

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?

Effusion in the knee joint

During palpation of the client's knee, the nurse compresses the suprapatellar pouch against the client's femur with one hand while feeling on each side of the patella with the opposite hand. For which of the following problems is the nurse assessing?

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

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:

5/5

How would the nurse document normal muscle strength?

Stenson's ducts

In examining a client's mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following?

fibrous.

Joints may be classified as cartilaginous, synovial, or

Small bowel obstruction

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?

increased thoracic curve

On inspection of the spine of a 79-year-old man, the nurse might expect to find a(n)

False

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

Environmental

Risk factors in which of the following areas are most readily changed to reduce the potential risk for falls?

Anterior nosebleeds

The Kiesselbach plexus is the most common site for what?

- VII - IX - XII

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)

left check under eye

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?

Shoulder abduction

The nurse asks the client to "raise the arm out to the side" in the position shown. What is the nurse assessing?

Candida albicans infection.

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely

Kyphosis

The nurse is assessing an elderly client and finds an exaggerated thoracic curve. This would be documented as what?

scoliosis.

The nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. The nurse suspects that the client is experiencing

Impaired physical mobility

The nurse is developing a plan of care for a client found to have a strength problem. What would be an appropriate nursing diagnosis for this client?

Gauze pad

The nurse is preparing to examine a patient's mouth floor. To move the tongue to one side for this examination, the nurse will use a:

maxillary sinuses.

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the

Phalen's

The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90° and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse performing on this patient?

Produces red blood cells

The nurse is working with a client who has leukemia, which affects the red marrow of the bones. The nurse understands that which of the following is characteristic of red marrow?

Vitamin deficiency

The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client?

Warm and humidify inspired air

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?

Scoliosis

The school nurse notes that the client carries her left shoulder higher than her right shoulder. You should recognize the likely presence of what health problem?

shoulder joint.

The subacromial bursae are contained in the

Wharton ducts.

The submandibular glands open under the tongue through openings called

frenulum.

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

2+

Upon assessment of the tonsils, the nurse finds them to be obstructing 30% of midline. This nurse would document this as what?

Reports of tingling, numbness, and pain in the involved wrist

What finding should a nurse expect when performing Phalen's test on a client with suspected carpal tunnel syndrome?

"Have you noticed a popping or grating sound when you chew?"

What is an appropriate question by the nurse to ask a client about the presence of temporomandibular joint dysfunction?

Flexion

What range of motion is the nurse testing by asking a client to stoop to pick an object off the floor?

"upper and lower extremity muscle strength is 5/5 bilaterally"

When assessing muscle tone and strength, the nurse would document expected findings as

Comparing one side to the other

When determining a client's strength, it is necessary to implement what assessment?

Cancers often occur.

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where:

Herniated disc

When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what?

Vestibule, nasal passages, and nasopharynx

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the:

Depress the tongue slightly off center

Which action by a nurse is appropriate to prevent the gag reflex during observation of the uvula?

Ask the client to say "aaah"

Which action by the nurse is appropriate to provide a clear view of the uvula for observation?

Flexion

Which movement should the nurse instruct the client to perform to assess range of motion for the knee?

Tongue fissures

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

rotator cuff tear.

While assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. The nurse plans to refer the client to a physician for possible

herniated disc.

While examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. The nurse should refer the client to a physician for possible

Warm the inspired air

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?