Sherpath Lesson Ch. 15, 16, 17: Ears, Nose, and Throat

When inspecting the nasal septum, which features should the nurse assess? Select all that apply. Crusting Bleeding Alignment Perforation Tenderness

Crusting Bleeding Alignment Perforation

Which finding is expected when assessing the tonsils? Dark red tonsils Hypertrophied tonsils Exudate on the tonsils Crypts with food particles

Crypts with food particles

What method should be used to inspect the middle ear of a 2-year-old patient? Pull the pinna up and out. Pull the pinna straight back. Pull the pinna up and back. Pull the pinna down and back.

Pull the pinna up and back.

As part of the history of present illness, which questions should the nurse ask a patient presenting with a nosebleed to learn more about the potential predisposing factors? Select all that apply. "Are you experiencing any nasal congestion or fever?" "Have you been struck in the nose recently?" "Have you noticed your nasal passages feeling dry?" "When did the nosebleed start?" "How long do the nosebleeds last when you have them?"

"Are you experiencing any nasal congestion or fever?" "Have you been struck in the nose recently?" "Have you noticed your nasal passages feeling dry?"

To assist in the examination of the soft palate of a young child, what question should the nurse ask the patient? "Do you brush your own teeth?" "Can you pant like a puppy?" "Can you take a deep breath?" "Did you have any surgeries on your mouth when you were a baby?"

"Can you pant like a puppy?"

Which questions should the nurse ask a patient with hearing loss regarding the timing of symptoms as part of the hx of present illness? "Did the hearing loss begin suddenly?" How long has the hearing loss lasted?" "Are you sensitive to loud noises?" "Are you experiencing any pain?" "Is the hearing loss constant or intermittent?"

"Did the hearing loss begin suddenly?" How long has the hearing loss lasted?" "Is the hearing loss constant or intermittent?"

Choose which medical-surgical history questions to ask a patient presenting with ear pain. Select all that apply. "Did your parents have tubes put in their ears as children?" "Did you experience frequent ear infections during childhood?" "Have you ever been diagnosed with labyrinthitis?" "Do you clean your ears with cotton-tipped applicators?" "Do you use ear drops for the pain?"

"Did you experience frequent ear infections during childhood?" "Have you ever been diagnosed with labyrinthitis?"

The nurse should ask the patient presenting with dental pain which questions as part of the history of present illness? "Do you wear dentures?" "Have you noticed any areas of irritation?" "How long have you had the pain?" "Do you have any family history of dental disease?" "How often do you see a dentist?"

"Have you noticed any areas of irritation?" "How long have you had the pain?"

Which questions should the nurse ask a patient who has difficulty swallowing as part of the history of present illness? Select all that apply. "When did you first notice the difficulty swallowing?" "When you try to swallow liquid, does it come out of your nose?" "Do you cough or have a choking sensation when you swallow?" "Have you ever been diagnosed with acid reflux or esophageal problems?" "How many cigarettes do you smoke daily?"

"When did you first notice the difficulty swallowing?" "When you try to swallow liquid, does it come out of your nose?" "Do you cough or have a choking sensation when you swallow?"

The nurse expects to find _______ permanent teeth in the adult patient.

32

The nurse should ask the patient presenting with nasal drainage which questions regarding the history of present illness? Associated symptoms of sneezing and congestion Parent or family member with seasonal allergies Color and amount of drainage Unilateral or bilateral Seasonality

Associated symptoms of sneezing and congestion Color and amount of drainage Unilateral or bilateral Seasonality

The inner ear is composed of which of the following structures? Auricle Cochlea Tympanic membrane Stapes

Cochlea

Which features of the buccal mucosa should be inspected as part of a thorough ears, nose, and throat examination? Select all that apply. Color Masses Swelling Symmetry Ulcerations

Color Swelling Symmetry Ulcerations

Which of the following are normal findings of a nose examination? Columella directly midline Septum thicker posteriorly than anteriorly Hairs in vestibule Inferior and middle turbinates visible Nares asymmetrical

Columella directly midline Hairs in vestibule Inferior and middle turbinates visible

Which mouth and oropharynx assessment finding is expected for the child? Mottled teeth Deciduous teeth Black or grey teeth Caries on upper incisors

Deciduous teeth

Which age-related finding is expected in a 55-year-old patient? Hearing loss Loss of vision Loss of sense of smell Decrease in sense of taste

Decrease in sense of taste

The nurse assesses a patient complaining of difficulty swallowing that began 1 month ago. The nurse notes the presence of enlarged tonsils, dry mucous membranes, and white spots on the tonsils. Which assessment information should the nurse document as history of present illness related to the ears, nose, and throat (ENT) assessment? Enlarged tonsils Difficulty swallowing White spots on the tonsils Dry mucous membranes The fact that the difficulty swallowing began 1 month ago

Difficulty swallowing The fact that the difficulty swallowing began 1 month ago

The nurse has a 36-year-old patient who is complaining of ear pain and difficulty hearing. The patient reports a family history of hearing loss. The patient has ear drainage and a retracted tympanic membrane on examination. Which should the nurse document as objective data related to the ear assessment? Difficulty hearing Ear pain Ear drainage and retracted tympanic membrane Family history of hearing loss

Ear drainage and retracted tympanic membrane

What structure prevents food from entering the lungs? Uvula Hard palate Palatine tonsils Epiglottis

Eploglottis

Which finding should the nurse note as normal when assessing the mouth and throat of an infant? Adherent white patches on the buccal mucosa Epstein pearls Persistent drooling after age 6 months not associated with teething Presence of natal teeth

Epstein pearls

Which information suggestive of a thyroid condition should be documented under family history? Tachycardia Neck pain on palpation Spouse with Graves disease Father with Graves disease

Father with Graves disease

The nurse should ask the patient with ear pain about which associated symptoms as part of a hx of present illness? Fever Ear drainage Decreased hearing ability Previous ear pain Association with exercise

Fever Ear drainage Decreases hearing ability

During the examination of the ears, which finding is expected? Auricle scales Low-set ears Flexible earlobes Tenderness on palpation

Flexible earlobes

During ear assessment of a 62-year-old patient, the nurse notes a buildup of cerumen and irritation in the ear canal. The patient reports a family history of Meniere disease and complains of muffled hearing. Which subjective assessment information should be documented as a part of the family history related to the ear assessment? Muffled hearing Buildup of cerumen Irritation of the ear canal History of Meniere disease

History of Meniere disease

The nurse is caring for a patient with complaints of hoarseness, sore throat, and difficulty swallowing. The nurse notes redness in the oropharynx and swollen tonsils. Which information suggestive of tonsillitis should the nurse document as history of present illness? Hoarseness Sore throat Swollen tonsils Difficulty swallowing Redness of the oropharynx

Hoarseness Sore throat Difficulty swallowing

Which nasal assessment findings, suggestive of inhaled cocaine abuse, are considered abnormal? Hyperemia Polyps Rhinorrhea Edema of the nasal mucosa

Hyperemia Rhinorrhea Edema of the nasal mucosa

A patient with a history of ear trauma complains of right ear pain and muffled hearing. The nurse notes loss of high- and low-frequency sounds. Which objective information should be documented as a part of the ear assessment? Select all that apply. Ear pain Muffled hearing History of ear trauma Loss of low-frequency sounds Loss of high-frequency sounds

Loss of low-frequency sounds Loss of high-frequency sounds Rationale: Ear pain and muffled hearing is hx of present illness, hx of ear trauma is medical-surgical hx

Which question about environmental exposure should the nurse ask a patient presenting with hearing loss as part of the personal/social history? Hot, dry air Air pollutants Dust and allergens Loud, continuous noises

Loud, continuous noises

The ossicles of the inner ear include which small bones? Select all that apply. Tympanic Malleus Stapes Incus Maxilla

Malleus Stapes Incus

The nurse should assess for which findings by palpating the nose? Masses Tenderness Nasal flaring Shape and size Position of bones and cartilage

Masses Tenderness Position of bones and cartilage

A patient complains of hoarseness, throat pain, and difficulty swallowing. The nurse notes a bruit over the thyroid and neck swelling. Which information should the nurse document as objective data? Hoarseness Throat pain Neck swelling Difficulty swallowing Bruit over the thyroid

Neck swelling Bruit over the thyroid

Which mouth and throat assessment findings should be considered abnormal? Nodule on the palate, not at the midline Tonsils that project beyond the tonsillar pillars Intact gag reflex Asymmetrical lips Red spots at the Stensen duct

Nodule on the palate, not at the midline Tonsils that project beyond the tonsillar pillars Asymmetrical lips Red spots at the Stensen duct

Which nose assessment findings should be considered abnormal? Noisy breathing or occlusion Patient unable to smell Perforated or deviated septum Deviation of uvula Hyperemia, rhinorrhea, and edema of mucosa

Noisy breathing or occlusion Patient unable to smell Perforated or deviated septum Hyperemia, rhinorrhea, and edema of mucosa

What are the functions of the nose? SATA Odor identification Emission of air for vocalization Passage of air during respiration Humidification, filtration & warming of inspired air Resonance of laryngeal sounds

Odor identification Passage of air during respiration Humidification, filtration, and warming of inspired air Resonance of laryngeal sounds

A patient presents with a complaint of impaired smell and nasal stuffiness. The patient reports use of intranasal cocaine and oral tobacco products. The nurse notes inflamed oral and nasal mucosa. Which subjective information should the nurse document as a part of the personal/social history related to the ear, nose, and throat (ENT) assessment? Nasal stuffiness Oral tobacco use Impaired smell Intranasal cocaine use Inflamed oral mucosa

Oral tobacco use Intranasal cocaine use

When the sinuses are palpated, which findings should be considered abnormal? Pain Swelling Tenderness Opaque glow on transillumination Dim red glow on transillumination

Pain Swelling Tenderness Opaque glow on transillumination

A patient with a history of dental caries reports pain with chewing. The patient smokes 1 pack of cigarettes each day and reports no dental visits for several years. The nurse notes a foul odor from the mouth and multiple discolored teeth. Which subjective assessment data should the nurse document as personal/social history related to a mouth assessment? Foul mouth odor Pain with chewing History of dental caries Patient's cigarette habit

Patient's cigarette habit Rationale: Foul mouth odor- Objective data Pain with chewing- Hx of present illness Hx of dental caries- Pt's medical hx

What ear assessment finding should be considered part of the normal aging process? Tinnitus Epistaxis Angioedema Presbycusis

Presbycusis Rationale: Tinnitus- Ringing in the ears Epistaxis- Nose bleeding Angioedema- Swelling in lower layer of skin

When gathering medical-surgical history about a patient who presents with postnasal drip, which conditions should the nurse ask about? Select all that apply. Headaches Thyroid disease Seasonal allergies Recurrent sinusitis Chronic postnasal drip

Seasonal allergies Recurrent sinusitis Chronic postnasal drip

When inspecting the dorsum of the tongue, the nurse should note which features? Size Color Coating Ulcerations Tenderness

Size Color Coating Ulcerations

In which positions could an infant be placed to perform the otoscopic examination? Supine Prone Sitting Left side-lying Dorsal recumbent

Supine Prone Sitting

Which of the following are normal findings of a mouth and throat examination? Uvula at midline Dorsal surface of tongue glistening Lips symmetrical vertically but not horizontally Hard palate continuous with the soft palate 32 teeth, firmly anchored

Uvula at midline Dorsal surface of tongue glistening Hard palate continuous with the soft palate 32 teeth, firmly anchored

Which ear assessment findings would be considered abnormal? Vertigo Tinnitus Darwin tubercle Preauricular pits Hearing loss

Vertigo Tinnitus Hearing loss

In which ways should the nurse evaluate a young child's hearing? Select all that apply. Use the Snellen E chart or HOVT chart. Whisper words with meaning to the child. Have the child repeat phrases the nurse yells. Inspect the tympanic membrane for perforations. Ask the child to perform tasks using a soft voice.

Whisper words with meaning to the child Ask the child to perform tasks using a soft voice