Health Assessment Chapter 18 Practice Questions

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

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

deviated septum

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

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?

"Are you experiencing any tooth pain?"

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.

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

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

3+

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?

4+

The Kiesselbach plexus is the most common site for what?

Anterior nosebleeds

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

Ask the client to say "aaah"

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

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.

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

Candida albicans infection.

The nurse notes that a client's gums are swollen and overgrown. What should the nurse include when assessing this client?

Current medications

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

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

Which characteristic of the gums should a nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?

Enlarged, reddened

During an assessment the nurse observes the condition shown in the client's mouth. What should the nurse suspect is occurring with this client?

Gingival hyperplasia

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

An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result?

Instruct the client to remove upper dentures.

A hospitalized client who suffered a recent stroke hasn't started a diet yet and has referrals in to speech therapy, occupational therapy, and physical therapy. What is the nurse's best action at mealtime?

Keep the client NPO until speech therapy has seen client.

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

Kiesselbach plexus

A client has returned from outpatient surgery where a biopsy revealed a nodule on the laryngopharynx. The client asks where this is located. What is the best response by the nurse to the client about the location of laryngopharynx?

Lowest portion of the pharynx

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)

The nurse observes a white patchy area in the pharyngeal fossa of a client. What is the nurse's best action?

Prepare client for a biopsy of the lesion.

A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.)

Press up on the frontal sinuses from under the bony brows. Press up on the maxillary sinuses.

Which instructions should the nurse provide to the client taking a sublingual medication?

Put the medication underneath your tongue.

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 initially?

Recognize that the sense of smell decreases with age

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?

Red, bleeding

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

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

Which glands are responsible for mouth drainage? Select all that apply.

Sublingual Submandibular Parotid

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.

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue?

Use a square gauze pad to hold the client's tongue to each side

Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia?

Vegetable omelet

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 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

The submandibular glands open under the tongue through openings called

Wharton ducts

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

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the

area underneath the tongue.

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 client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

laryngeal cancer

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

maxillary sinuses

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?

reddish

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should

refer the client for further evaluation

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

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 rich blood supply of the nose serves to

warm inspired air