Chapter 16 Physical Assessment

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.

2

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.

2

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.

1

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.

1

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.

1

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.

1

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.

1

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.

1

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? Standard Text: Select all that apply. 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.

1, 4

During the focused interview, the client confides in the nurse issues with anxiety. During the physical assessment, which findings support the presence of anxiety? Standard Text: Select all that apply. 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

1, 2, 4

During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? Standard Text: Select all that apply. 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.

1, 3

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? Standard Text: Select all that apply. 1. Streptomycin. 2. Steroid inhalers. 3. Aspirin. 4. Neomycin. 5. Acetaminophen.

1, 3, 4

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? Standard Text: Select all that apply. 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.

1, 3, 5

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.

2

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.

2

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."

2

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.

2

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."

2

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.

2

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.

2

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? Standard Text: Select all that apply. 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.

2, 3, 4

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? Standard Text: Select all that apply. 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."

2, 5

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.

3

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?"

3

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.

3

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.

3

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

3

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? Standard Text: Select all that apply. 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.

3, 5

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.

4

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.

4

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."

4

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."

4