HA Ears, Nose, Mouth, and Throat Prep U

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 experiencing sinus pressure and congestion?'

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following would the nurse include in the teaching?

"Avoid substances that could be irritating to your mouth."

A nurse is interviewing a client as part of a routine examination of his ears and hearing. The nurse notes that this client has high blood pressure. Which of the following questions regarding his hearing should the nurse ask that is associated with his high blood pressure?

"Do you experience any ringing, roaring, or crackling in your ears?"

A 61-year-old man has visited the clinic at the prompting of his wife, who states that his hearing is becoming less acute. Which of the following assessment questions is most useful in determining whether the man's hearing loss is sensorineural or conductive?

"Do you find that you have particular difficulty understanding people's speech?" Explan:A hallmark of sensorineural hearing loss is difficulty in understanding speech. It would be prudent to assess for loss of balance and vertigo and to identify any pitch-dependent characteristics, but these would be less useful in differentiating between conductive and sensorineural hearing loss. Hearing loss is not noted to correlate with other sensory losses.

A client reports the onset of tinnitus. What question should the nurse ask the client to further assess this condition?

"Have you taken any antibiotics in the past few weeks?" Explan: Tinnitus is the feeling of ringing in the ears and may be associated with excessive wax buildup, high blood pressure, or certain ototoxic medications, such as antibiotics. Cleaning the ear with cotton-tipped applicators places the client at risk for ear damage. Ear infections can cause loss of hearing. Not hearing the p hone ring may be a sign of hearing loss.

The mother of a small child with tubes in both eardrums asks the nurse if it is okay if the child travels by airplane. What is the nurse's best response?

"It's safe to fly because the tubes will equalize pressure." Explanation: Pressure equalization tubes equalize pressure on either sides of the eardrum; so it's a great time to fly if one has tubes in the ears. The child should wear ear plugs to keep water out of the ears when swimming. Wearing ear plugs while flying may diminish the pressure equalization advantage of the tubes. Clients do not have to avoid flying for any period of time after tube placement. Ear tubes do not have an effect on immunocompromised clients.

An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response?

"You can wrestle after the lesions stop weeping and have crusted over." Explan: Herpes simplex virus is very contagious. Wrestling is a close contact sport, therefore the client should not wrestle until the lesions have stopped weeping and have fully crusted over. It's nearly impossible to cover lesions on the lips. Repeat cultures are not routinely performed for this condition.

The results of a client's Rinne test are as follows: bone conduction > air conduction. How should the nurse explain these findings to the client?

"You have a conductive hearing loss." Explanation: The Rinne test tests for conductive hearing loss. The client's results indicate that bone conduction is greater than air conduction which indicates conductive hearing loss. Air conduction should be twice as long as bone conduction. The whisper test evaluates loss of high frequency sounds. An audiogram can reveal a nerve related or unilateral hearing loss.

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

3+

In which client would the nurse identify receding gums as an expected assessment finding?

A 77-year-old man who describes himself as being healthy

Upon examination, the Advanced Practice Nurse finds that a patient has otitis media with effusion. What assessment finding is most clearly indicative of this diagnosis?

A diffuse cone of light Explanation: A diffuse cone of light indicates otitis media with effusion.

The nurse notes a tophus of the ear of an older adult. Which assessment data is consistent with a tophus?

A hard nodule composed of uric acid crystals

The nurse notes a cyst on the ear of an older adult. Which assessment data is consistent with a cyst?

A sac with a membranous lining filled with fluid

A 55-year-old male client has just been diagnosed with presbycusis. In the interview with the client, the nurse should most expect the client to complain of having trouble hearing which of the following in the initial stages of this condition?

A story his wife is telling him

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 Explanation: The nursing diagnosis of Acute Pain can be confirmed because it meets the major defining characteristic of verbalization of sore throat. Impaired swallowing is not related to impaired neurologic or neuromuscular function. There is no criterion to confirm that this client cannot maintain health maintenance because this is an acute problem. No data exist to confirm the nursing diagnoses of Self-Care Deficit or Hopelessness.

Many older adults are edentulous, which can cause overclosure of the mouth. What can this lead to?

Angular cheilitis Explanation: Overclosure of the mouth may lead to maceration of the skin at the corners of the mouth; this condition is called angular cheilitis. It would not lead to Koplik's spots, a traverse ridge, or crusting.

When reviewing ear assessment, a student nurse would learn that the cone of light should be visible where on the tympanic membrane?

Anterior inferior quadrant

The Kiesselbach plexus is the most common site for what?

Anterior nosebleeds Explanation: The Kiesselbach plexus is the most common site for anterior nosebleeds.

While assessing the ears of an 8-year-old client, the nurse observes white spots on the tympanic membrane with no redness present. Which action would be most appropriate?

Ask the mother whether the child has had numerous ear infections.

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?

Asthma Explan: This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke. The other answers listed—chewing betel nuts, exposure to the sun, and heavy alcohol use—are all risk factors for oropharyngeal cancer, but not for sinusitis.

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 Explan: The tongue and buccal mucosa may appear smoother and shiny from papillary atrophy and thinning of the buccal mucosa. This condition is called smooth glossy tongue and may result from deficiencies of riboflavin, folic acid, and vitamin B 12.

An alternate pathway that bypasses the external and middle ear is called what?

Bone conduction Explanation: An alternate pathway, known as bone conduction, bypasses the external and middle ear and is used for testing purposes.

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?

Both sides

When conducting the Weber test a client reports hearing the sound better in the right ear. What should this finding indicate to the nurse?

Conductive hearing loss in the right ear Explan: With conductive hearing loss, the client reports hearing the sound better in the poor ear which in this case is the right ear. The left ear is considered the "good" ear. This finding is not necessarily associated with an ear infection or a ruptured tympanic membrane.

A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. What assessment findings should the nurse anticipate along with this condition?

Crepitus over the maxillary sinuses Explan: With a sinus infection with large amounts of exudates, the nurse would most likely palpate crepitus over the maxillary sinuses. The frontal or maxillary sinuses would be tender. The tympanic membrane would be red and tender with acute otitis media. Increased amounts of saliva are unrelated to the findings of a sinus infection.

The teeth are composed of what three layers? Select all that apply.

Crown, Neck and Root

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?

Diets low in fruits and vegetables are a possible risk factor for oral cancer.

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

Dysphagia Explan: Dysphagia can lead to aspiration and is the priority concern to maintain a patent airway. A weak gait can lead to falls but is not priority over airway. Right ptosis, or eyelid drooping,and facial weakness can inhibit certain facial movements but this is not a priority concern over airway.

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 Explan: The nurse should inspect the Wharton's ducts on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right side of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate sites to inspect for salivary ducts.

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

False

When performing the cover test, the nurse would cover one of the client's eyes and then ask the client to do which of the following?

Focus on a distant object, looking for movement in the other eye

When inspecting the tympanic membrane, which of the following structures does the nurse expect to identify?

Handle of malleus, short process of malleus, cone of light Explan: Visualization of the tympanic membrane using an otoscope includes inspection of the cone of light, the short process of the malleus, and the handle of the maleus. The cochlea, vestibule, and stapes (part of the ossicles) are not normally visualizable.

The eustachian tube is a passage between the middle ear and the nasopharynx. What is the function of the eustachian tube?

Helps to regulate pressure in the middle ear Explanation: The eustachian tube, a conduit that connects the middle ear to the nasopharynx, allows for pressure regulation of the middle ear. The other options do not accurately describe the function of the eustachian tube.

Which finding should a nurse recognize as normal when assessing the ears of an elderly client?

High-tone frequency loss

When providing client teaching about the ears, what should the nurse be sure to include?

How the client cleans the ears Explan: It is important to address how the client cleans the ears. Many people associate cerumen in the ear canal with lack of hygiene and therefore clean their ears routinely. Often, patients think that cotton-tipped applicators are for this purpose. This self-care behavior is unsafe, placing clients at risk for cerumen impaction. Nurses should reinforce proper cleaning techniques. Since cleaning with cotton-tipped applicators is not correct, the nurse would not teach the client how to use the applicators to clear the ears. The nurse would not teach the client about basic anatomy and physiology of the ears. The option of potential infection from self-cleaning of ears is not correct.

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following?

Otitis externa Explanation: A tender tragus is associated with otitis externa. Tenderness behind the ear would suggest otitis media. A ruptured tympanic membrane would be associated with ear pain and a popping sensation. Tenderness over the mastoid process would suggest mastoiditis.

A nurse is performing an otoscopic exam of a client's right tympanic membrane. At which location would the nurse document seeing the cone of light if it were in the appropriate place?

In the 5-o'clock position Explan: When examining the right ear, the cone of light would be in the 5-o'clock position. It would be in the 7-o'clock position in the left ear. The umbo would be located in the center.

The nurse is reviewing a client's electronic health record before assessing her mouth. Which diagnosis would the nurse recognize as an indication for immediate medical follow-up?

Leukoplakia Explan:Leukoplakia is a precancerous lesion that requires immediate follow-up. Thrush, gingivitis, and canker sores are abnormal findings, but the evidence of leukoplakia is serious and needs immediate evaluation and treatment.

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?

Maxillary Explan: Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses, which are located in the upper jaw. The ethmoidal and sphenoidal sinuses are smaller, located deeper in the skull, and are not accessible for examination.

The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?

Native Americans

While inspecting the client's tympanic membrane, the nurse notes a pearly gray and shiny appearance. The nurse would interpret this finding as what?

Normal tympanic membrane Explanation: The tympanic membrane is normally a pearly gray color with a shiny appearance. White spots would indicate scarring. A yellowish bulging membrane would suggest serous otitis media; a red bulging membrane would suggest acute otitis media. Otitis externa does not directly affect the appearance of the tympanic membrane.

The nurse palpates a client's auricles and notes an elarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify the healthcare provider about the finding.

The nurse is preparing to perform the Rinne test on a client. The nurse should place the tuning fork at which location first?

On the client's mastoid process Explan: For the Rinne test, the tuning fork base is place on the client's mastoid process and then it is moved to the front of the external auditory canal when the client no longer hears the sound. The tuning fork is placed in the center of the client's forehead or head for the Weber test.

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first?

On the mastoid process

Which statement regarding oral cancer is correct? Select all that apply.

Oral cancer occurs more frequently in males., Risk factors for oral cancer includes oral sex and Smoking is a risk factor for oral cancer. Explan: Oral cancer occurs more frequently in males. Oral sex and smoking are risk factors for oral cancer. Caucasians have a higher incidence of oral cancer. African Americans have a higher mortality related to oral cancer.

A nurse palpates a client's ear and finds that the tragus is exquisitely tender. The nurse should suspect what health problem?

Otitis externa

While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect?

Otitis externa

The nurse is preparing to examine a client's internal ear. Which equipment would be necessary?

Ottoscope Explanation: An otoscope is needed to examine a client's internal ear. A watch with a second hand would be important when performing the Romberg test. A tuning fork is needed to perform the Weber and Rinne tests. A measuring tape would not be needed for any portion of the ear assessment.

You are a pediatric nurse caring for a child who has been brought to the clinic with otitis externa. What assessment finding is characteristic of otitis externa?

Pain on manipulation of the auricle

The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis?

Pain on percussion Explan:The frontal and maxillary sinuses are tender upon percussion in clients with allergies or sinus infection. Percussion is not performed in an effort to gauge particular sounds.

A client presents to the health care clinic complaining of a sore throat. In examining the client's mouth and throat, the nurse notices that the tonsils on both sides of the oropharynx at the end of the soft palate are swollen. Which tonsils are these?

Palatine Explan: Masses of lymphoid tissue referred to as the palatine tonsils are located on both sides of the oropharynx at the end of the soft palate between the anterior and posterior pillars. The lingual tonsils lie at the base of the tongue. Pharyngeal tonsils or adenoids are found high in the nasopharynx. Paranasal refers to sinuses, not tonsils.

A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock?

Pallor Explan: Pallor around the lips is a finding in clients with anemia and shock. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Cyanotic lips are seen in cases of cold or hypoxia. Swelling of the lips is common in local or systemic allergic reaction.

A client has been diagnosed with conductive hearing loss. The nurse understands that which of the following could be the cause of this type of hearing loss?

Perforated eardrum

Which characteristic of the gums should a nurse expect to assess in a client who is healthy?

Pink, moist, firm

Which technique should the nurse use to examine the sinuses of a client with a sinus infection?

Press up on the brow on each side of the nose to palpate the frontal sinus. Explan:Objects should not be placed in the client's mouth unless necessary. Illumination of the frontal sinuses can be accomplished by placing the penlight on the brow of each side of the nose. The nurse should press up on the brow on each side of the nose to palpate the frontal sinus. Frontal and maxillary sinuses cannot be examined through an otoscope. Sinus cavities are not indirectly percussed but may be tapped lightly to detect pain.

What action should the nurse implement when assessing the ear of an adult client using an otoscope?

Pull the auricle out, up, and back. Explanation: The nurse should pull the auricle out, up, and back to straighten the external auditory canal. This is because the external auditory canal is S-shaped in the adult. The outer part of the canal curves up and back, and the inner part of the canal curves down and forward. The nurse should choose the largest speculum that fits the client's ear. The nurse should hold the speculum in the dominant hand and insert the speculum gently down and forward.

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the gums and teeth?

Put on gloves and retract the client's lips and cheeks. Explan: Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.

Which assessment of the tongue should a nurse recognize as abnormal?

Red with loss of papillae Explan: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B 12 or niacin. The normal tongue has visible veins on the ventral surface and is pink or pale in color and moist. A normal variation seen in the older client is a fissured, topographical map-like tongue.

The emergency department nurse notes a clear, watery discharge from the client's ear following a bicycle accident. Which of the following actions should the nurse do next?

Refer the client immediately for further evaluation. Explan: Watery drainage may suggest cerebrospinal fluid, for which the client should be referred immediately for further evaluation. Tophi and postauricular cysts would be visible on inspection and are not associated with drainage. Repositioning the patient is not a priority, due to the potential severity of the client's injury.

When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority?

Referring the client for further evaluation Explan: A bluish-black line along the gum line is seen in lead poisoning. Therefore the nurse needs to refer the client for further evaluation. Phenytoin therapy can lead to gingival hyperplasia. Smoking may cause yellowish or brown teeth or a yellow-brown coating on the tongue. The finding is not suggestive of inadequate mouth care. However, information about proper mouth care would be important for any client, regardless of the findings.

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.

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 nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to

firmly pull the auricle out, up, and back.

The nurse notes that an older client has white spots on the tympanic membrane of the left ear. What should this finding indicate to the nurse?

Scars from previous ear infections Explan: White spots on the tympanic membrane are scars from previous ear infections. A red bulging eardrum is an indication of acute otitis media. Yellowish bulging membrane is associated with serous otitis media. A perforated ear drum indicates trauma from a current infection.

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

A patient is diagnosed with otosclerosis, a condition in which the auditory ossicles develop a spongy consistency, which results in conductive hearing loss. It appears that the worst site is the inner most bone, which transmits sound waves through the oval window. Which bone is this?

Stapes

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?

Stenson's ducts Explan: Stenson's ducts (parotid ducts) are located on the buccal mucosa across from the second upper molars and, in a healthy mouth, are visible with flow of saliva and with no redness, swelling, pain, or moistness in area. Wharton's ducts are openings from the submandibular salivary glands and are located on either side of the frenulum on the floor of the mouth. Foster's and Burton's are not the names of actual ducts.

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

Sublingual, Submandibular and Parotid Explan: The sublingual, parotid and submandibular glands are responsible for mouth drainage. Sebaceous glands may be located on tongue. The lacrimal duct is part of the nose.

A client comes to the trauma unit in respiratory distress following a motor vehicle accident. On examination, the nurse notices that the trachea is deviated from the midline. What does this finding indicate?

Tension pneumothorax

The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say "aaah." This finding should prompt the nurse to focus on which of the following during subsequent assessment?

The client's neurological status Explan: Deviation of the uvula or lack of movement of the soft palate suggests cranial nerve damage or stroke. Further neurological assessment and referral is necessary. This abnormal finding is not associated with immune, respiratory, or nutritional deficits.

Which action by the nurse is consistent with Weber's test?

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

Which action by the nurse is consistent with the Rinne test?

The nurse strikes the tuning fork and places it on the patient's mastoid process to measure bone conduction.

A nurse practitioner is assessing the tympanic membrane of a client who has come to the clinic. What would the nurse practitioner expect to visualize if the client has a normal otoscopic evaluation?

The short process of the malleus Explan: During visualization of the normal tympanic membrane, it is intact and translucent and the short process of the malleus is visible. The nurse practitioner would not expect to see the stapes or the head of the incus.

A 52-year-old patient fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

The vestibular portion of the inner ear Explanation: Failure of the Romberg test may indicate dysfunction in the vestibular portion of the inner ear, semicircular canals, and vestibule.

Which of the following findings from the health history of a 70-year-old woman with tinnitus is likely most significant to her diagnosis?

The woman takes aspirin 4 times daily to treat her rheumatoid arthritis. Explan: Excessive use of aspirin can cause tinnitus. A history of TIAs and cancer is not likely to be related, nor is the use of antihypertensives.

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?

There is a sensorineural hearing impairment.

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection. On inspection of the patient's tongue, the nurse should anticipate what appearance?

Thick, white plaques on the tongue surface

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include?

Thoroughly chew small amounts of food with each mouthful. Explanation: Dysphagia, difficulty swallowing, increases the risk of aspiration. Thoroughly chewing small bites of food decreases this risk and is most critical for safety. Fully raising the head of the bed prevents aspiration. Dysphagia is not associated with temporomandibular joint pain, and the patient may drink during meals unless explicitly contraindicated.

The three salivary glands also contain drainage ducts. Which drainage ducts are associated with the submandibular gland?

Wharton's ducts Explan: The submandibular gland is beneath the body of the mandible. Its Wharton ducts run deep to the floor of the mouth and open on both sides of the frenulum. The parotid (Stensen's) duct opens into the mouth in the buccal mucosa just opposite the upper second molar. The small sublingual salivary gland lies within the floor of the mouth under the tongue with many openings along the submandibular duct.

Upon examination of the ear with an otoscope, the nurse documents the skin of the ear canal as thickened, red, and itchy. The nurse would expect this finding with a diagnosis of

chronic otitis media Explan: n/a

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

don clean gloves for the procedure.

The cone of light is located in the... a) inner ear b) middle ear c) external ear d) semicircular ear

external

When inspecting a client's teeth, the nurse notes gingival hyperplasia. What should the nurse assess to determine the cause for this finding?

medications

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

position the handle of the otoscope to one side. Explan: Position the otoscope's handle to the side to improve your view of the structures. If an otoscope is unavailable, use a penlight and hold the tip of the nose slightly up. A nasal speculum with a penlight also facilitates good visualization.

The roof of the oral cavity of the mouth is formed by the anterior hard palate and the

soft palate. Explanation: The roof of the oral cavity is formed by the anterior hard palate and the posterior 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

touching each other.

A nurse performs a hearing test on an elderly client. Which result should the nurse recognize as an indication that presbycusis is present? An inability to hear:

whispered sounds Explan: The inability of the client to hear whispered sounds indicates presbycusis, which is a gradual sensorineural hearing loss due to degeneration of the cochlea or vestibulocochlear nerve, common in older clients. The inability to hear the calling bell may indicate deafness. The inability to hear the tuning fork may indicate sensorineural or conductive hearing loss.

A client describes headaches as severe and lasting for days. Which question would be most appropriate to use to determine if these headaches are migraines?

"Do you have any visual changes before the headache?"

A client's nasal mucosa is pale reddish-blue. What should the nurse ask the client to validate this finding?

"Do you sneeze a lot when around fresh cut grass or pollen?" Explan: In allergic rhinitis the nasal mucosa may be pale blue or red. A perforated septum is associated with inhaled substances. Thick discolored mucus or gross pus is seen with an infection. Absence of normal structures suggests previous nasal surgery.

The nurse notes thrush on the palate of a patient. The most appropriate question the nurse should ask is

"Have you been on antibiotics recently?"

The patient asks the nurse why the nurse put the tuning fork on the bone behind the ear. Which is the best response by the nurse?

"It identifies a problem with the normal pathways for sound to travel to your inner ear."

The nurse tests the distant visual acuity of several clients and records the findings. Which finding indicates that the client with the poorest vision?

20/60

The nurse is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following?

3+ Explanation: Tonsils that touch the uvula are identified as 3+. Tonsils that are visible are graded as 1+; midway between tonsillar pillars and uvula as 2+; touch each other as 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?

4+ Explan: The nurse should document the tonsillar grading as 3+ because the tonsils are enlarged and touching the uvula. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are just visible. Tonsils that are so enlarged that they touch each other are graded 4+.

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, "I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies." What would the nurse do next?

Ask the client about the timing of his allergy symptoms. Explanation: Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round. Transillumination and otoscopic examination will not help identify the cause of the client's allergy symptoms. Similarly, the response of the allergies to antihistamines will not determine the ultimate cause of the symptoms.

During an assessment the nurse learns that a client has been experiencing tinnitus "for weeks." Which medication should the nurse consider as causing this client's symptom? Select all that apply.

Aspirin and Furosemide Explan: Tinnitus or ringing in the ears may be associated with certain ototoxic medications which include furosemide and aspirin. Tinnitus is not identified as an adverse effect of digoxin, verapamil, or acetaminophen.

When providing client education on hearing, the nurse should remind clients to utilize ear plugs when they are what? (Select all that apply.)

At train stations, Using lawnmowers, and At concerts

A 49-year-old administrative assistant comes to the office for evaluation of dizziness. The nurse elicits that the dizziness is a spinning sensation of sudden onset and worsens with changes of head position. The episodes last a few seconds and then go away, and are accompanied by intense nausea. The client has vomited once. She denies tinnitus. The nurse examines the client's head and neck and notes that her hearing is intact to Weber and Rinne and that there is nystagmus. Her gait is normal. Based on this description, what is the most likely diagnosis?

Benign positional vertigo

Which of the following would be most important to assess when a client is noted to be a mouth breather?

Checking for deviated nasal septum Explan: Inability to breathe through the nose may indicate sinus congestion, obstruction, or a deviated septum. It would not be necessary to ask if the client experiences dry mouth often; the client would most likely answer yes. Dental caries would be unrelated to the client's breathing through the mouth. Asking about other symptoms is too general and would not provide information specific to the client's status.

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as which of the following?

Consensual response

A nurse is inspecting the ears of an Asian client and observes that her earlobes appear soldered, or tightly attached to adjacent skin with no apparent lobe. Which of the following should the nurse do next?

Continue with the examination

A nurse is examining a client's nose. Which characteristics of the nasal mucosa should the nurse expect to find if the client is healthy?

Dark pink, moist, and free of discharge

A 12-year-old boy was brought to the emergency department after being hit in the head with a ball during a baseball game. What assessment finding would suggest to the nurse trauma to the middle ear or inner ear?

Dark red or bluish tympanic membrane

An avid swimmer presents with ear pain. Her history includes pain and drainage from the left ear. On examination, she has pain when the ear, including the tragus, is manipulated. The canal is narrowed and erythematous with some white debris in the canal. The rest of the examination is normal. What diagnosis would be most appropriate for this client?

External otitis Explan: This is a classic history and examination of a client suffering from external otitis. Otitis media would not usually include pain with movement of the external ear or drainage unless the eardrum was perforated. In this case, the examination of the eardrum is recorded as normal. Cholesteatoma is a growth behind the eardrum and would not account for these symptoms. Otitis media would classically be accompanied by a bulging, erythematous eardrum.

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

Eye drops and sucking on hard candy may used to relieve dryness. Explanation: Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness. Sjogren syndrome does not affect blood pressure. Sjogren syndrome is not contagious or sexually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness

A six-month old male infant is brought to the emergency department by his parents for inconsolable crying and pulling at his right ear. When assessing this infant the nurse is aware that the tympanic membrane should be what color in a healthy ear?

Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal.

A client has a sensorineural hearing loss. Which condition would the nurse most likely identify as a cause?

Inner ear problem Explanation: Sensorineural hearing loss is related to the dysfunction of the inner ear. A perforated eardrum, otosclerosis, or otitis media would most likely cause a conductive hearing loss, since these would affect structures in the external or middle ear.

The nurse is performing an ear assessment of an adult client. Which action constitutes the correct procedure for using an otoscope when examining the client's ears?

Inserting the speculum down and forward into the ear canal Explanation: The nurse should insert the speculum gently down and forward into the canal. Using the dominant hand, the nurse should position the hand holding the otoscope against the client's head or face. The largest speculum that fits comfortably into the client's ear canal is used.

A client presents to an ambulatory clinic with purulent, bloody drainage of the ear. What would the nurse assess first?

Inspect the client's external ear canal. Eplanation: Purulent, bloody drainage suggests external otitis, an infection of the external ear canal. Therefore the nurse would need to inspect the external auditory canal. Assessing the tympanic membrane would be appropriate if the client has purulent drainage, pain, and complained of a popping sensation, which is associated with otitis media and tympanic perforation. Palpation of the tragus is not an immediate priority in cases of suspected external otitis. Hearing assessments may later be indicated, but these would not be performed at the beginning of the assessment.

Place the following actions in the appropriate order to conduct an ear examination.

Inspect the ears Choose appropriate sized speculum Pull the helix up and back Rotate the otoscope slightly Visualize the entire tympanic membrane Explanation: After inspecting the ears and choosing the correct sized speculum, the nurse should hole the client's ear at the helix and lift up and back to align the canal for best visualization. After visualization of the canal, the otoscope should be rotated slightly to be able to visualize the entire tympanic membrane.

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The mother states 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

After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw?

Maxillary Explanation: The maxillary sinuses are located in the upper jaw. The frontal sinuses are located above the eyes. The ethmoidal and sphenoidal sinuses are located deeper in the skull and not accessible for examination.

The nurse's assessment of an older adult client's ears and hearing suggests the possible presence of conductive hearing loss. What is the most likely etiology of this abnormal assessment finding?

Otitis media

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) Explan: Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A bifid or split uvula is a common finding in the Native American population. A cerebrovascular accident may cause asymmetrical or loss of movement of the uvula. Infection of the tonsils does not cause a deviation of the uvula and failure of the palate to rise.

Which statement reflects accurate documentation by the nurse of a normal, left tympanic membrane?

Pearly gray, translucent, with cone of light at 7 o'clock position Explanation: A normal tympanic membrane should be pearly gray, shiny, translucent. The cone of light in the left ear is located at the 7 o'clock position. The cone of light will be located at the 5 o'clock position in the right ear. A tympanic membrane that is pink or red may exhibit an absent light reflex and indicate acute otitis media. A yellow color to the tympanic membrane with bulging or protrusion indicates the presence of fluid

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?

Receding and ischemic gums Explanation: The gums recede, become ischemic, and undergo fibrotic changes as a person ages. A bifid uvula is a common finding in Native Americans, not among older adults. Brown spots on the chewing surface of teeth is an indication of tooth decay and is not associated with aging per se, nor are enlarged palatine tonsils, which are an indicator of tonsillitis.

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

Red, bleeding Explan: Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. A grey-white line along the gum line is seen in cases of lead poisoning.

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

The nurse is completing a client's ear assessment. What assessment finding would indicate the need to perform Weber's test?

The client has unilateral hearing loss. Explan: The whisper test evaluates loss of high-frequency sounds. The Weber test helps to differentiate the cause of unilateral hearing loss. In the Rinne test, use of a tuning fork helps the nurse determine if hearing is equal in both ears and if there is either a conductive or a sensorineural hearing loss by allowing the nurse to compare the difference in bone conduction (BC) versus air conduction (AC). Remember AC has less resistance than BC. Option D is a distracter for this question.

The nurse notes otitis media with effusion in the left ear of a 3-year-old child. Which assessment data is consistent with otitis media with effusion?

Redness and bulging of the eardrum Explanation: Redness and bulging of the eardrum are characteristic of otitis media with effusion. Clear or bloody discharge occurs with rupture of the tympanic membrane. Dense white patches on the tympanic membrane are noted with scarring of the tympanic membrane.

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. What nursing action would be most appropriate?

Refer the client for further evaluation.

The nurse is assessing a client complaining of swelling in the neck. While palpating the neck, the nurse finds a 2-cm lump that is fixed and hard. Why does this finding require emergency investigation?

This could be a sign of cancer

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?

Thrush

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

When assessing a patient the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils?

Tonsils are T3

The nurse teaches the client that overuse of this medication can cause rebound nasal congestion.

Topical decongestants Explanation: Topical decongestants can cause rebound nasal congestion. Anticoagulants may cause epistaxis. Antihistamines and antidepressants can cause drying of the mucous membranes.

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem?

Use of cotton swabs inside the ear Explanation: Use of cotton-tipped applicators inside the ear can cause earwax to become impacted and cause ear damage. Absence of drainage would be normal. Earplug use when swimming would be an appropriate measure to prevent swimmer's ear. A history of one ear infection would not necessarily indicate a problem. However, recurrent ear infections would.

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

Vegetable omelet Explan: Dietary recommendations for this bleeding disorder include decreasing foods high in salicylates, such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E. A vegetable omelet would be the most appropriate food choice since it doesn't contain salicylates or antiplatelet supplements.

A nurse is teaching about hygiene and the prevention of illness. When instructing clients how to clean their ears, what action should the nurse recommend?

Washing with a warm, moist washcloth

A client who works in a manufacturing plant is attending a teaching session on plant safety. Which of the following would be an important risk prevention measure to teach regarding hearing?

Wearing ear guards whenever inside the plant

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

The submandibular glands open under the tongue through openings called

Wharton ducts.

During examination 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 Explanation: The nurse should inspect the Wharton's duct on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right sides of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate to inspect salivary ducts.