Chapter 12 Ears, Nose, Mouth, and Throat

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?" "When did you have surgery on your nose?" "How often do you inhale substances?" "How long have you had a head cold?"

"Do you sneeze a lot when around fresh cut grass or pollen?" Explanation: 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 is assessing a client with chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? "How often do you take Tylenol?" "Would you say that you eat a balanced diet?" "How often do you use over-the-counter nasal sprays?" "How many drinks of alcohol do you have in a typical day?"

"How often do you use over-the-counter nasal sprays?" Explanation: Overuse of nasal sprays may cause nasal irritation, nosebleeds, and rebound swelling. These symptoms are not characteristic of poor nutrition or heavy alcohol use. Acetaminophen does not result in bleeding or chronic nasal congestion.

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." "You have nerve damage in your ears." "You have a unilateral hearing loss." "You have a high frequency hearing loss."

"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 is assessing a client's tonsils and note that they touch the uvula. The nurse would document this finding as which of the following? 1+ 2+ 4+ 3+

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 finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A large amount of exudate in the sinuses A perforated septum Obstruction of the nostril by a foreign object Normal, air-filled sinuses

A large amount of exudate in the sinuses Explanation: 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. Normal, air-filled sinuses would not demonstrate crepitus. Obstruction of the nostril by a foreign object would prevent sniffing or blowing air through the nostrils, but would not produce crepitus. A perforated septum would also not produce crepitus.

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

Above the eyes Explanation: The frontal sinuses are located above the eyes. The maxillary sinuses are located above the jaw.

Otoscopic examination of a 69-year-old client's tympanic membrane reveals that it is red, bulging, and distorted. The nurse also notes a diminished light reflex. To what should the nurse most likely attribute this assessment finding? Acute otitis media Trauma Repeated ear infections Age-related changes

Acute otitis media Explanation: A red, bulging eardrum coupled with distorted, diminished, or absent light reflex is associated with acute otitis media. Repeated ear infections usually cause the formation of white scar tissue. Trauma causes the accumulation of blood behind the eardrum, which appears blue or dark red.

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? Ask the client to say "aaah" Press firmly on the back of the tongue Depress the tongue slightly off center Ask the client to stick out the tongue

Ask the client to say "aaah" Explanation: Asking the client to say "aaah" and instructing him or her to open the mouth wide makes the uvula more clear for observation. The nurse should depress the client's tongue slightly off center to prevent the gag reflex during observation of the uvula. Depressing the back of the tongue would elicit the gag reflex. Having the client stick out the tongue would not provide a clear view of the uvula.

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

Asthma Explanation: 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? C K B12 D

B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin.

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

Cancers often occur. Explanation: It is important to inspect the sides and undersurface of the tongue and the floor of the mouth, because these are areas where cancer most often develops.

The nurse identifies this as trapping debris and propelling it toward the nasopharynx. Lacrimal duct Columella Cilia Turbinates

Cilia Explanation: Cilia capture and propel debris toward the nasopharynx. Turbinates are bony lobes that project from the lateral walls of the nasal cavity. The lacrimal duct receives drainage. The columella divides the nostrils.

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 I (olfactory) Cranial nerve VII (facial) Cranial nerve X (vagus) Cranial nerve XII (hypoglossal)

Cranial nerve XII (hypoglossal) Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion. Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. A loss of taste discrimination occurs with a defect of cranial nerve VII (facial). The palate fails to rise and the uvula deviates to the side with cranial nerve X (vagus) paralysis.

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? Hypertrophied adenoids Deviated septum Swollen nasal passages Obstructed turbinate

Deviated septum Explanation: The nurse assesses the client's nares for patency when inserting a tube into the nose for feeding. A deviated septum or obstructed nares may make insertion difficult. The nares may be obstructed, but the turbinate would not be. If the client is breathing through the nose, the nurse would not suspect swollen nasal passages. The nurse would not suspect hypertrophied adenoids in an older adult client.

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

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? Yellowish-white Red Gray Bluish-white

Gray Explanation: The healthy tympanic membrane appears pearly gray and is positioned obliquely at the base of the ear canal. This makes options A, B and D incorrect.

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 Protects the middle ear Allows for drainage of fluid from the middle ear Maintains fluid in the middle ear

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? Decrease in cerumen production Shortened earlobes Bulging tympanic membrane High-tone frequency loss

High-tone frequency loss Explanation: Presbycusis, a gradual hearing loss, is common after the age of 50 years. It begins with a loss of the ability to hear high-frequency tones. Cerumen production may increase in older age or become drier and build up as the cilia become more rigid. The earlobes become elongated in older age. A bulging tympanic membrane is not a normal finding at any age.

A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? Prolonged tonsillar enlargement History of allergies Incomplete immunization record History of epistaxis (nosebleeds)

History of allergies Explanation: Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Immunizations are unlikely to relate directly to this sign. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa, hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis or other infectious processes.

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

How to reduce periodontal disease Explanation: Major risk reduction and health promotion goals in assessment of the nose, sinuses, mouth, and throat are related to various issues, including tobacco use, obstructive sleep apnea, oral health, and cancer. Health goals include reducing periodontal disease.

During the health interview, a client reports an occasional blockage in the upper portion of the nasal passage. The nurse understands the most pronounced effect this would have on the client would be what? Occasional dizziness Impaired sense of smell Difficulty hearing Decreased sense of taste

Impaired sense of smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell. A decreased ability to taste would be associated with an upper respiratory infection or lesion of the facial nerve. Difficulty hearing or occasional dizziness is associated with ear and vestibular problems.

During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom? Inability to smell Occasional dizziness Difficulty hearing Decreased sense of taste

Inability to smell Explanation: Receptors for cranial nerve I (olfactory) are located in the upper part of the nasal cavity and septum. Blockage would decrease the ability to smell. A decreased ability to taste would be associated with an upper respiratory infection or lesion of the facial nerve. Difficulty hearing or occasional dizziness are associated with ear problems.

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.

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 African Americans Italian Americans Non-Hispanic Americans

Native Americans Explanation: A bifid uvula is a common assessment finding in Native Americans.

The nurse is preparing to perform the Rinne test on a client. The nurse would place the tuning fork at which location first? Center of client's forehead In front of the external auditory canal At the base of the skull On the mastoid process

On the mastoid process Explanation: 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 place in the center of the client's forehead or head for the Weber test.

A nurse palpates a client's ear and finds that the tragus is tender. The nurse suspects which of the following? Mastoiditis Ruptured tympanic membrane Otitis externa Otitis media

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.

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? Ear infection Teeth problems Otitis externa Sinus infection

Otitis externa Explanation: Pain caused by "swimmer's ear," or otitis externa, differs from pain felt in middle-ear infections. If you can wiggle the outer ear without pain, the condition is most likely not swimmer's ear. Earache (otalgia) can also occur with ear infections, cerumen blockage, sinus infections, or teeth and gum problems.

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? Tophi on the pinna and ear lobe Pain on manipulation of the auricle Air bubbles visible in the middle ear Dark yellow cerumen in the external auditory canal

Pain on manipulation of the auricle Explanation: Tophi are deposits of uric acid crystals and are generally painless; they are a common physical assessment finding in clients diagnosed with gout. Cerumen is a normal finding during assessment of the ear canal. Its presence does not necessarily indicate that inflammation is present. Pain when the nurse pulls gently on the auricle in preparation for an otoscopic examination of the ear canal is a characteristic finding in clients with otitis externa. Air bubbles in the middle ear may be visualized with the otoscope; however, these do not indicate a problem involving the ear canal. Aural tenderness or pain is not usually associated with middle ear disorders.

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? Injury to the organ of Corti Perforated eardrum Damage to cranial nerve VIII Dysfunction of the temporal lobe of the brain

Perforated eardrum Explanation: The transmission of sound waves through the external and middle ear is referred to as conductive hearing and the transmission of sound waves in the inner ear is referred to as perceptive or sensorineural hearing. Therefore, a conductive hearing loss would be related to a dysfunction of the external or middle ear (e.g., impacted ear wax, otitis media, foreign object, perforated eardrum, drainage in the middle ear, or otosclerosis). A sensorineural loss would be related to dysfunction of the inner ear (i.e., cranial nerve VIII, temporal lobe of brain, or organ of Corti).

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media? Gray, translucent, with no retraction Pearly, translucent, with no bulging Yellowish, bulging, with fluid bubbles Red, bulging, with an absent light reflex

Red, bulging, with an absent light reflex Explanation: A client with acute otitis media would have a red, bulging eardrum, with absent light reflex. A pearly, translucent membrane, with no bulging is a normal finding in the tympanic membrane. A yellowish, bulging membrane, with bubbles is seen in serous otitis media. A gray, translucent membrane, with no retraction is a normal finding in the tympanic membrane.

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? Clear discharge in the ear canal Redness and bulging of the eardrum Bloody discharge in the ear canal Dense white patches on the tympanic membrane

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 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? Examine for postauricular cysts. Assess for foreign body impaction. Position the client to facilitate drainage. Refer the client immediately for further evaluation.

Refer the client immediately for further evaluation. Explanation: 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 client is not a priority, due to the potential severity of the client's injury.

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

Rinse mouth with antifungal medication as prescribed. Explanation: The client's symptoms are consistent with oral candidiasis which is common in clients taking antibiotics. The tongue will become further irritated if attempts are made to completely scrape off the coating or if the mouth is rinsed with peroxide. Since this condition is commonly caused by antibiotic use, then another antibiotic for the tongue would not be prescribed.

A client with advanced presbycusis admits to the nurse that he was nearly involved in a car accident because he could not hear the siren of an ambulance that was crossing an intersection through which he was driving. The client says that he lives alone and has no one else to drive him. Which of the following diagnoses can the nurse make at this time? Readiness for Enhanced Communication related to expressed desire for a hearing aid Impaired Social Interaction related to hearing loss Risk for Loneliness related to hearing loss Risk for Injury related to hearing impairment

Risk for Injury related to hearing impairment Explanation: The nurse should recognize that this client is at risk for injury related to his hearing impairment because of his near-accident. Although the client lives alone, there is no explicit evidence that he is at risk for loneliness due to his hearing impairment. There is also no indication of impaired social interaction due to his hearing impairment. The client has not expressed a desire for a hearing aid.

A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses? Sit with the head erect and at the eye level of the nurse Tilt the head backwards with the neck flexed Prone with arms relaxed at the sides Semi-recumbent position with the chin lifted

Sit with the head erect and at the eye level of the nurse Explanation: The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a Semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination & palpation of the sinuses more difficult for the examiner.

The nursing instructor is discussing ear problems. What would the instructor indicate is an abnormal finding? Sclerotic tympanic membrane Tenderness of the apex Tenderness of the mastoid process Atrophied lymph nodes

Tenderness of the mastoid process Explanation: Normal ear findings on physical assessment are firm auricles without lumps, nonpalpable lymph tissue, nontender ears, and no pain elicited during palpation or manipulation of the auricle. No pain should occur with palpation of the mastoid process. Enlarged lymph nodes indicate pathology or inflammation. Pain with auricle movement or tragus palpation indicates otitis externa or furuncle. Sclerosis of the tympanic membrane is a variation of normal ear findings. Atrophied lymph nodes and tenderness of the apex are not assessment findings for the ear.

Which action by the nurse is consistent with Weber's test? The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear. The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears.

The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. Explanation: Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. In Rinne's test, the nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

Which action by the nurse is consistent with the Rinne test? The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. The nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear. The nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears. The nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane.

The nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Explanation: In the Rinne test, the nurse strikes the tuning fork and places it on the client's mastoid process to measure bone conduction. Using Weber's test, the nurse activates the tuning fork and places it on the midline of the parietal bone in line with both ears to differentiate the cause of unilateral hearing loss. When examining the inner ear, the nurse uses a bulb insufflator attached to an otoscope to observe movement of the tympanic membrane. In the Whisper test, the nurse shields their mouth and whispers a simple sentence approximately 18 inches from the client's ear.

Upon inspection of a Native American client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding? Enlargement of the tonsils with infection is a common cause. This is often a normal finding in the Native American population. Paralysis of cranial nerve X (vagus) nerve is likely to be present. The client should be assessed for a cerebrovascular accident (CVA).

This is often a normal finding in the Native American population. Explanation: A bifid or split uvula is a common finding in the Native American population. Clients with a bifid uvula may have a submucous cleft palate. A CVA may cause asymmetrical or loss of movement of the uvula. Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. Enlargement of the tonsils does not cause a bifid uvula.

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 Explanation: Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate.

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

Torus palatinus Explanation: Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple.

Which of the following, if obtained during the health history, would alert the nurse to a possible ear-related problem? Ear infection one time at age 3 Absence of drainage Use of cotton swabs inside the ear Earplug use when swimming

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? Salad with ginger dressing Vegetable omelet Garlic chicken Chocolate pudding

Vegetable omelet Explanation: 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.

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

Vestibule, nasal passages, and nasopharynx Explanation: After entering the anterior nares, air enters the vestibule and passes through the narrow nasal passage to the nasopharynx.

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? Cleaning with cotton-tipped applicator Washing with a warm, moist washcloth Gently irrigating with normal saline Irrigating with mildly soapy water

Washing with a warm, moist washcloth Explanation: A warm, moist washcloth should be used to clean the outside of the ears, but nothing (including fluids) should be inserted into the ear canal.

A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? XII III VI VIII

XII Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve. The third cranial nerve is involved with eye muscle movement. The sixth cranial nerve is involved with lateral eye movement. The eighth cranial nerve is involved with hearing and equilibrium

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of trauma from infection. acute otitis media. serous otitis media. skull trauma.

acute otitis media. Explanation: In acute otitis media there is a bulging red membrane with decreased or absent light reflex.

As a part of the ear examination for hearing loss, a nurse conducts a Weber test on a client. To accurately perform this test the nurse should place the base of the tuning fork: at the center of the client's forehead in front of the external auditory canal. on the client's mastoid process. behind the external auditory canal.

at the center of the client's forehead Explanation: During a Weber test for assessment of hearing loss, the nurse should place the tuning fork at the center of the client's forehead. Placing the base of the tuning fork at the client's mastoid process and placing the prongs of the tuning fork in front of the external auditory canal are part of the Rinne test. Placing the base of the tuning fork in front of the external auditory canal is an inappropriate technique.

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. Explanation: The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the temporal bone. It is connected to the floor of the mouth by a fold of tissue called the frenulum.

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

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

touching each other. Explanation: 4+ Tonsils touch each other.