Health Assessment Prep U: Chapter 18-Assessing Mouth Throat Nose and Sinuses

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?

cheek

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 Gingivitis Petechiae Fordyce granules

Leukoplakia

Which assessment of the tongue should a nurse recognize as abnormal? Ventral surface with visible veins Red with loss of papillae Pale pink and moist Fissured, topographical pattern

Red with loss of papillae

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? Pink, moist, firm Red, bleeding A grey-white line Enlarged, reddened

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 Bluish gray, swollen, with watery exudate Dark pink, moist, & free of discharge Pale pink, swollen, with watery exudate

Red, swollen, with purulent discharge

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? Pallor Cyanotic Reddish Swelling

Reddish

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client? "Are you taking high blood pressure medication?" "Do you have a family history of severe headaches?" "Are you experiencing sinus pressure and congestion?' "Have you ever had an injury to your head or neck?"

"Are you experiencing sinus pressure and congestion?'

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? A grey-white line Pink, moist, firm Red, bleeding Enlarged, reddened

A grey-white line

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 perforated septum A large amount of exudate in the sinuses Obstruction of the nostril by a foreign object Normal, air-filled sinuses

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? 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

The nurse assesses the frontal sinus where? Above the eyes Below the eyes Above jaw Below jaw

Above the eyes

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? Ineffective Health Maintenance Self-Care Deficit Hopelessness Acute Pain

Acute Pain

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 bacterial rhinosinusitis Acute otitis media

Acute bacterial rhinosinusitis

The Kiesselbach plexus is the most common site for what? Posterior nosebleeds Sinusitis Infections Anterior nosebleeds

Anterior nosebleeds

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? Exposure to the sun Chewing betel nuts Heavy alcohol use Asthma

Asthma

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? At the very tip Posteriorly near tonsils Frenulum Both sides

Both sides

The nurse is performing assessment of moving cheek to the side with wooden stick. What is the nurse assessing in this client? Glandular function Dentition Buccal mucosa Tongue alignment

Buccal mucosa

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

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 leukoplakia. Candida albicans infection. Fordyce spots. Koplik spots.

Candida albicans infection.

During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding? Diphtheria Candidiasis Torus palatinus Kaposi sarcoma

Candidiasis

During a physical examination the nurse observes the condition shown on a client's hard palate.(white patches) How should the nurse document this finding? Diphtheria Candidiasis Torus palatinus Kaposi sarcoma

Candidiasis

A nurse is working with a client who has an impaired ability to smell. 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 V (trigeminal) Cranial nerve VII (facial) Cranial nerve I (olfactory) Cranial nerve IX (glossopharyngeal)

Cranial nerve I (olfactory)

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. Act as resonance chambers during speech Decrease the weight of the skull Help break down and lubricate food Protect against infection Assist with moving food and swallowing

Decrease the weight of the skull Act as resonance chambers during speech

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

Difficulty swallowing

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

Dysphagia

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

Either side of the frenulum on the floor of the mouth

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

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

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

False

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

Gingival hyperplasia

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse would document this finding as being: Angioedema Angular cheilitis Actinic cheilitis Herpes simplex

Herpes simplex

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? Dyspnea Dysphagia Alopecia Hoarseness

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

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 How to safely put an infant to bed with a bottle How oral cancer is diagnosed Beginning dental care in children at age 5

How to reduce periodontal disease

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? Reassure the mother that this is common in children Assess for allergies to antibiotic Have the child blow the nose to assess drainage Inspect the nostrils with an otoscope

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

Kiesselbach's plexus

An older client who wears dentures complains of having sore gums. What can the nurse instruct the client to help with this problem? Use toothpaste containing fluoride. Massage the gums every day. Have a dental examination every 2 years. Avoid excessive intake of sugary foods.

Massage the gums every day.

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? Sphenoidal Maxillary Ethmoidal Frontal

Maxillary

What is the common channel for the respiratory and digestive systems? Oropharynx Frenulum Sinuses Nares

Oropharynx

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

Overuse of nasal spray may cause rebound congestion.

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

Put the medication underneath your tongue.

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

Receding and ischemic gums

A client is upset because the right medial incisor tooth is broken at the gum line. Which tooth on the diagram is the client referring to?

Right big front tooth

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 antifungal medication as prescribed. Scrape off the white coating with a toothbrush. Apply the prescribed topical antibiotic gel as directed. Clean mouth and tongue with hydrogen peroxide and water.

Rinse mouth with antifungal medication as prescribed.

The nurse is performing the assessment under eyes. What is the nurse assessing in this client? Turbinates Sense of smell Sinuses Nasal septum

Sinuses

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? Diabetic ketoacidosis Small bowel obstruction Respiratory infection End-stage liver disease

Small bowel obstruction

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? Diphtheria Torus palatinus Thrush Kaposi's sarcoma

Thrush

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? Kaposi's sarcoma Thrush Torus palatinus Diphtheria

Thrush

The nurse is teaching at a community clinic. She explains to the clients that what increases the risk for head and neck cancer? Select all that apply. Alcohol Tobacco products Pollens Pet dander Mold

Tobacco products Alcohol

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? Tongue fissures Peritonsillar abscess Candidiasis Deviated septum

Tongue fissures

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? Torus palatinus Leukoplakia Thrush (candidiasis) Kaposi's sarcoma

Torus palatinus

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

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

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

Vestibule, nasal passages, and nasopharynx

A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate? Vitamin B12 deficiency Vitamin C deficiency Vitamin D deficiency Vitamin B1 deficiency

Vitamin B12 deficiency

The nurse notes that the client's tongue appears as red inflamed and crack. What should the nurse suspect is occurring with this client? Cranial nerve XII damage Vitamin deficiency Recent use of antibiotics Yeast infection

Vitamin deficiency

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? Clean the inspired air Warm the expired air Clean the expired air Warm the inspired air

Warm the inspired air

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

Wharton ducts.

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 to best confirm a complication of the treatment? White coated tongue Red and white patches in the throat Swollen uvula White patches firmly attached to the buccal mucosa

White coated tongue

During an assessment the nurse observes the client's throat as shown(uvula goes to one side). Which cranial nerve should the nurse suspect is damaged in this client? IX VII I X

X (10)

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? allergic rhinitis epistaxis acute bacterial sinusitis rhinitis medicamentosa

acute bacterial sinusitis

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. don clean gloves for the procedure. offer the client mouthwash.

don clean gloves for the procedure.

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 frenulum. soft palate. gums. mandible.

frenulum.

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

gloves penlight tongue depressor

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 mostlikely? gingivitis aphthous ulcers dysphagia hypothyroidism

hypothyroidism

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

soft palate.

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 midway between the tonsillar pillars and uvula. visible upon inspection. touching the uvula. touching each other.

touching each other.

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

warm the inspired air.