CHAPTER 16 Ears, Nose, Mouth, and Throat

Select all that apply. During the focused interview, the client confides in the nurse issues with anxiety. During the physical assessment, which findings support the presence of anxiety? 1. The client complains of pain when the tragus is gently manipulated. 2. The client has several small ulcers on her lip. 3. Pale nasal mucosa 4. Small sores are noted within the mouth. 5. Perforated nasal septum

Correct Answer: 1, 2, 4 Pain that occurs with manipulation of the tragus may accompany temporomandibular joint dysfunction that may be associated with jaw clenching. Jaw clenching can accompany psychological stress. Clients who are under a great deal of stress might bite their lips. Clients who are under a great deal of stress might present with ulcers in their mouth. Pale nasal mucosa is associated with cocaine use, infection, hypoxia, and allergies. A perforated nasal septum is associated with cocaine use.

The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums. The client states that regular oral hygiene is performed and that she does not understand why this has occurred. Which response by the nurse is the most appropriate? 1. "You may have oral cancer." 2. "You are experiencing a normal change during pregnancy." 3. "You may have leukoplakia." 4. "You need to decrease the frequency of your oral hygiene."

Correct Answer: 2 Gingival hyperplasia (enlargement of the gums) is a normal physiologic change associated with pregnancy. It is also seen in clients with leukemia and prolonged use of Dilantin.

The nurse is examining a toddler client. The toddler has a fever and the nurse notes the ear canal is red and swollen, and the presence of purulent drainage. Based on this assessment data, which diagnosis does the nurse anticipate? 1. Otitis media. 2. Otitis externa. 3. Hemotympanum. 4. Tophi.

Correct Answer: 2 Otitis externa is an infection of the external auditory canal manifested by red, swollen ear canal, fever, and purulent drainage.

The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect? 1. Acute otitis media. 2. Recent trauma. 3. Blocked Eustachian tubes. 4. History of frequent middle ear infections.

Correct Answer: 2 The presence of a darkened area on the tympanic membrane is most likely due to blood in the middle ear and may be indicative of recent trauma.

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data? 1. Administer IV fluids. 2. Provide oral hygiene. 3. Administer oxygen. 4. Provide a warm drink.

Correct Answer: 3 Pallor and cyanosis of the oral cavity and lips are assessment findings that indicate hypoxia. The nurse should apply oxygen for the client.

The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal. When performing the Weber test, which would the nurse expect to learn? 1. Air conduction is longer than bone conduction. 2. Bone conduction is longer than air conduction. 3. Sound lateralized to the right ear. 4. The client is unable to maintain balance while standing.

Correct Answer: 3 The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other. With impacted cerumen, an ear infection, or a perforated tympanic membrane, the sound will lateralize to the affected ear during the Weber test.

The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include? 1. Bleeding and inflamed gums. 2. Smooth and shiny tongue. 3. Red, swollen tonsils. 4. Ulcerations on the lip or under the tongue.

Correct Answer: 4 Oral cancers are most commonly found on the lower lip or the base of the tongue. They do not heal normally.

An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client? 1. Presbycusis. 2. Mastoiditis. 3. Otitis media. 4. Otitis externa.

Correct Answer: 1 Age-related changes include loss of low- and high-frequency hearing, also known as presbycusis.

The nurse educator is conducting an in-service for a group of community health nurses. Which is an objective for Healthy People 2020 that the nurse will include in the in-service? 1. Increasing the use of health-care related use of the Internet. 2. Increasing the use of antibiotics for viral infections. 3. Increasing the age for the first dental assessment. 4. Increasing the incident of dental caries.

Correct Answer: 1 Healthy People 2020 aims to increase healthcare-related use of the Internet among individuals who are experiencing sensory loss, including hearing deficits.

The emergency department triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days. When assessing patency of the nares, the nurse notes that the child is unable to breathe through the right nostril. Which interpretation of the assessment data by the nurse is the most appropriate? 1. Produced by severe nasal inflammation or obstruction. 2. Normal for a child. 3. A result of chronic allergies. 4. A result of sinusitis.

Correct Answer: 1 If the client cannot breathe through each naris, severe inflammation or an obstruction may be present.

The client is experiencing the effects of a recent cerebrovascular accident (CVA). The client is unable to smell. Which cranial nerve was most likely affected by the CVA? 1. Cranial nerve I. 2. Cranial nerve XII. 3. Cranial nerve VIII. 4. Cranial nerve VII.

Correct Answer: 1 The sense of smell is controlled by cranial nerve I.

The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. Based on this data, which does the nurse suspect? 1. Rhinitis. 2. Perforated septum. 3. Previous epistaxis. 4. Nasal polyps.

Correct Answer: 1 These clinical manifestations are associated with rhinitis. Rhinitis is inflammation of the nasal mucosa due to a viral infection or allergy.

The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. Which action by the nurse is appropriate in this situation? 1. Pull the pinna up and back, then reinsert the otoscope. 2. Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced. 3. Reinsert the otoscope quickly and press against both sides of the inner auditory canal. 4. Pull the pinna down and back, then reinsert the otoscope.

Correct Answer: 1 To avoid trauma to the ear, the otoscope is to be removed and the pinna should be pulled up and back for better visualization.

Select all that apply. During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? 1. The nurse notes that the nasal septum has perforated. 2. Temporomandibular joint pain when the client opens and closes the mouth. 3. The septum is noted to be very pale in color. 4. Yeast infection of nasal mucosa and in mouth. 5. Difficulty swallowing water.

Correct Answer: 1, 3 When a client is abusing cocaine, the nurse may note that the nasal septum has broken down and has even perforated. When a client is abusing cocaine, the nasal mucosa might appear vasoconstricted and very pale in color. Temporomandibular joint pain could be the result of otitis externa or might indicate temporomandibular joint dysfunction. It is unrelated to cocaine use. Steroid inhalers can cause growth of Candida in the nose, mouth, or throat. It is unrelated to cocaine use. If the client experiences difficulty in swallowing, this may be due to a neurological or gastrointestinal problem, or it may be related to ill-fitting dentures or malocclusion.

Select all that apply. The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? 1. Streptomycin. 2. Steroid inhalers. 3. Aspirin. 4. Neomycin. 5. Acetaminophen.

Correct Answer: 1, 3, 4 Streptomycin is an antibiotic that can cause hearing loss. Aspirin can cause ringing in the ears. Neomycin is an antibiotic that can cause hearing loss. Steroid inhalers are associated with Candida (yeast infections) in the nasal mucosa. Acetaminophen is not associated with hearing loss.

Select all that apply. A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? 1. Request information from the client regarding increased propensity for bruising or bleeding. 2. Assess the tonsils for redness or swelling. 3. Obtain a blood pressure. 4. Check for deviated septum. 5. Request information from the client to determine if there was any recent thin, watery drainage from the nose.

Correct Answer: 1, 3, 5 The client may have a blood coagulation disorder that may result in increased bruising or bleeding. This disorder may have produced the episodes of epistaxis. Hypertension is a contributory factor to the occurrence of nosebleeds. The nurse should assess the client's blood pressure to determine if it is elevated. Thin, watery drainage from the nose is associated with rhinitis. Rhinitis is associated with epistaxis. Red, swollen tonsils are associated with tonsillitis. Tonsillitis is not associated with epistaxis. A deviated septum is not associated with epistaxis.

Select all that apply. The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? 1. Irrigating with warm mineral oil, peroxide, and flushing with warm water. 2. Inserting a sharp instrument to break up the ear wax. 3. Irrigating with a cold solution. 4. Inserting a cerumen spoon to remove the wax. 5. Irrigating with warm sudsy water.

Correct Answer: 1, 4 Care must be taken when removing cerumen. Warmed mineral oil and peroxide soften the earwax and the ear can be irrigated with warm water afterwards. The cerumen can also be safely removed with a cerumen spoon. The cerumen spoon is designed to remove the wax safely without risking injury or perforation of the eardrum. Sharp instruments should not be placed within the ear canal because it may injure the tympanic membrane. Cold solutions may harden the ear wax, making it more difficult to remove. Warm, sudsy solutions may irritate the ear canal.

The nurse educator is teaching a group of students about cultural differences to consider when conducting an ear, nose, and throat assessment. Which statement by a nursing student indicates appropriate understanding of the information presented? 1. "Asians are more likely to experience greater difficulty with otitis media than people from other cultures." 2. "Sometimes in Asians and Native Americans, their ear wax looks dry and dark." 3. "Asians have a higher risk of having issues associated with cleft lips and cleft palates." 4. "Asians have a high incidence of tooth decay."

Correct Answer: 2 Cerumen appears dry and gray to brown in Asians and Native Americans. Cerumen found in Caucasians and African Americans looks moist and yellow-orange in color.

The nurse is assessing several children in a pediatric clinic. Which child is experiencing a development delay? 1. The 6-year-old child has lost two deciduous teeth. 2. The 26-month-old child has one baby tooth. 3. The 4-month-old infant is drooling. 4. The 2-month-old infant's salivary glands are not producing saliva.

Correct Answer: 2 Deciduous (baby) teeth begin to erupt between 6 months and 2 years of age. A 26-month-old child might be expected to have more than one deciduous tooth.

A young mother brings an infant to the pediatric clinic. The infant has had a fever and is pulling at the left ear. Based on this data, which disorder does the nurse suspect? 1. Sinusitis. 2. Otitis media. 3. Tonsillitis. 4. Otitis externa.

Correct Answer: 2 Fever and hearing loss are clinical manifestations associated with otitis media. The auditory canal of infants is shorter and has an upward curve that persists until about the age of 3. In addition, their auditory tube is more horizontal than the adult, which leads to easier migration of organisms from the throat to the middle ear. Infants and children with otitis media often display the behavior of pulling at their ears.

A client presents in the healthcare provider's office with complaints of headache and malaise. During the assessment, the nurse notes the client is experiencing severe pain when palpating behind the ears. Based on this data, which diagnosis does the nurse anticipate? 1. Sinusitis. 2. Mastoiditis. 3. Chronic allergies. 4. Anemia.

Correct Answer: 2 Mastoiditis is associated with pain and tenderness over the mastoid process, which is located behind the client's ears.

The client admits to cleaning his ears with a cotton-tipped applicator. As a consequence, the client has developed impacted cerumen and unilateral hearing loss. As the nurse prepares the client's plan of care, which nursing diagnosis is most applicable? 1. Acute pain. 2. Knowledge deficit. 3. Acute confusion. 4. Unilateral neglect.

Correct Answer: 2 Of the choices, the best nursing diagnosis for this client is knowledge deficit regarding how to adequately care for his ears. Another possible nursing diagnosis that would be applicable for this client is disturbed sensory perception because he will be unable to hear well out of the ear that is impacted with cerumen.

Which structure separates the vestibule from the mouth?

Correct Answer: 2 The vestibule is made up of the lips, buccal mucosa, outer surface of the gums and the teeth and cheeks. The mouth is separated from the vestibule by the teeth. The mouth is made up of the tongue, hard and soft palate, uvula, mandibular arch, and axillary arch.

The client has been brought via ambulance to the emergency department (ED) following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action? 1. Requesting information from the client regarding any chronic allergies. 2. Testing the drainage for glucose. 3. Asking the client if there have been recent middle ear infections. 4. Irrigating the ear with warm mineral oil or peroxide, and flushing with warm water.

Correct Answer: 2 When a client's ear is draining clear fluid, this might indicate the client has a cerebrospinal fluid leak. The fluid should be tested for glucose. Glucose is present in cerebrospinal fluid.

Select all that apply. The client has developed anosmia. The nurse educates the client about the possible causes of this condition. Which topics are appropriate for the nurse to include in the teaching session with the client? 1. Commonly associated with gingivitis. 2. Possibly linked to heredity. 3. Related to a diet deficient in zinc. 4. An indicator of a neurological problem. 5. Caused by dental caries.

Correct Answer: 2, 3, 4 Anosmia is the inability to smell. Anosmia may be related to a neurological disorder, genetic makeup, or a diet that is deficient in food containing zinc. It is unrelated to gingivitis. Clients with gingivitis and dental caries often complain of a bad taste in their mouth.

Which structure attaches the tongue to the floor of the mouth? 1. Hard palate. 2. Papillae. 3. Frenulum. 4. Alveoli sockets.

Correct Answer: 3 The frenulum connects the anterior portion of the tongue to the floor of the mouth.

Select all that apply. The nurse is discharging an infant who was brought to the emergency department for the treatment of an ear infection and fever. Which statements will the nurse include in the discharge teaching? 1. "The baby's last bottle before bedtime should only contain water." 2. "It is important not to prop the baby's bottle during feeding." 3. "You must rinse the baby's mouth right after the baby falls asleep." 4. "You must perform oral hygiene more frequently throughout the day." 5. "The last bottle of the evening should not be given just before the baby goes to sleep."

Correct Answer: 2, 5 A primary source of ear infection in infants and small children is the practice of propping the bottle with milk or juice. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. A major source of ear infection in infants and small children is the practice of giving the baby a bottle at bedtime. The sugar in these liquids remains in the mouth and contributes to the potential for infection in the throat, which travels through the shorter, narrower, and more horizontal auditory tube. Milk should not be replaced with water because the baby may not receive enough nutrition. Bottles should not be given just before bedtime. This would not be appropriate and might be dangerous for the baby. Providing oral hygiene for children immediately before bedtime might be helpful to help reduce the risk of ear infections. Increasing the oral hygiene frequency throughout the day will not improve this situation if bottle propping is occurring or if the baby is given a bottle immediately prior to bedtime.

The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data? 1. "Have you eaten licorice lately?" 2. "How often do you brush your tongue?" 3. "Have you recently taken antibiotics?" 4. "Have you ever had this happen before?"

Correct Answer: 3 The presence of a black, furry-looking coating on the tongue is usually related to an overgrowth of fungus due to inhibition of normal bacteria due to antibiotic use.

The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract? 1. Olfactory cells. 2. Columella. 3. Turbinates. 4. Nares.

Correct Answer: 3 The superior, middle, and inferior turbinates are specifically responsible for warming, moistening, and filtering the air before it enters the trachea and lungs.

Select all that apply. The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client? 1. Increasing risk of developing otitis externa. 2. Developing tophi along the outer rim of the ears. 3. Perforating the tympanic membrane. 4. Needing tympanostomy tubes. 5. Impacting cerumen.

Correct Answer: 3, 5 This client is at risk for perforating the tympanic membrane with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. This client is at risk for impacting the cerumen within the ears with the cotton-tipped applicator. The inside of the ear should not be cleaned. Cerumen moves to the outside of the ear canal naturally. Otitis externa is an infection of the client's outer ear. This client does not have an increased risk of developing otitis externa. Tophi are small white nodules that are found on the helix or antihelix. These nodules are a sign of gout and contain uric acid crystals. Tympanostomy tubes are placed when clients develop repeated otitis media infections. These tubes help relieve middle ear pressure and allow drainage that occurs as a result of the infection. This client does not require tympanostomy tubes.

The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which interventions will the nurse implement? 1. Allow the client to walk independently. 2. Obtain an order for a catheter. 3. Limit fluid intake. 4. Obtain a bedside commode.

Correct Answer: 4 A positive Romberg sign indicates problems with the vestibular apparatus that controls balance. This client might experience difficult ambulating and has a higher risk of falling. The nurse must help the client eliminate safely. Obtaining a bedside commode for the client will help prevent the client from falling while attempting to ambulate independently to and from the bathroom.

The nurse is explaining discussing the Rinne test to a group of student nurses. Which statement by the nurse is most appropriate? 1. "This test requires the use of an otoscope." 2. "The test is performed by whispering statements a few feet away from the client." 3. "The test is used to determine if a client hears sound in one ear better than the other." 4. "This test compares air and bone conduction of sound using a tuning fork."

Correct Answer: 4 The Rinne test compares air and bone conduction of sound with the use of a tuning fork.

The nurse is performing a focused interview with the client and asks the client if there has been any drainage from the ears. The client responds, "Yes." Which statement by the health care provider indicates that the client may have developed acute otitis media? 1. "The ear canal itself is really red, raw, and sore." 2. "I noticed that the drainage looked clear, like water." 3. "The drainage looks like what is draining from my nose, kind of clear and mucous-like." 4. "It is kind of yellowish-reddish color."

Correct Answer: 4 The client with acute otitis media will state that he is experiencing drainage from the ears that is purulent. Reddish-yellow drainage would be classified as purulent.

A client who is having difficulty maintaining equilibrium is unable to ambulate without pushing a wheelchair or using a walker. Which part of the ear is not functioning completely based on this assessment data?

Correct Answer: B The ear is divided into three areas: the external ear, the middle ear, and the inner ear. All three are involved in hearing, but only the inner ear is involved in equilibrium. The vestibular apparatus contained in the inner ear must be working adequately for the client to be able to maintain a sense of balance.