Chapter 18 Questions

What is the common channel for the respiratory and digestive systems? A. nares B. frenulum C. sinuses D. oropharynx

D

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? A. cranial nerve 12 (hypoglossal) b. Cranial nerve 10 (vagus) C. Cranial nerve 1 (olfactory) D. cranial nerve 7 (facial)

A

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? A. either side of the frenulum on the floor of the mouth B. buccal mucosa across the second upper molars C. right side of the frenulum at the base of the gums D. posterior aspect of the tongue bilaterally

A

You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? A. Hoarseness B. Dyspnea C. dysphagia D. alopecia

A

The nurse is planning instructions for a patient with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.) A. Safety measures because of a loss of smell B. importance to increase oral fluids C. expect a sore throat and difficulty swallowing D. remind that the voice may sound different E. How to breathe through the mouth

ABDE

A client reports having a dry sore throat for the last few days. What should the nurse consider as causing this client's symptom? Select all that apply. A. Dry heat irritation B. oral cancer C. viral infection D. allergy E. acid reflux

ACDE

A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect? A. frenulum B. both sides C. at the very tip D. posteriorly near tonsils

B

A client seeks medical attention for pain when touching the area of the frontal sinuses. Which should the nurse consider as the reason for this client's symptom? A. actue otitis media B. acute bacterial rhinosinusitis C. eye infection D. oropharyngitis

B

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? A. prone, with arms relaxed at the sides B. sitting with the head erect and at the eye level of the nurse C. semi-recumbent position with the chin lifted D. tilting the head backwards with the neck flexed

B

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? A. How oral cancer is diagnosed B. How to reduce periodontal disease C. how to safely put an infant to bed with a bottle D. beginning dental care in children at age 5

B

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 A. touching the uvula B. touching each other C. visible upon inspection D. midway between the tonsillar pillars and uvula

B

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? A. Columella B. Kiesselbach plexus C. rosenmuller fossa D. ala

B

Before examining the mouth of an adult client, the nurse should first A. don sterile gloves for the procedure B. don clean gloves for the procedure C. ask the client to leave dentures in place D. offer the client mouthwash

B

During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record? A. petechiae B. leukoplakia C. gingivitis D. fordyce granules

B

During the physical examination of the mouth, the nurse identifies vesicular eruptions along the client's lips and surrounding skin. The nurse should document which problem? A. actinic cheilitis B. herpes simplex C. angioedema D. angular cheilitis

B

The frontal sinuses are the only ones readily accessible to clinical examination. A. True B. False

B

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is composed of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? A. moisten and filter expired air B. warm and humidify inspired air C. cool and dry expired air C. move mucus to the back of the throat

B

When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: A. ala nasi, turbinates, and nasopharynx B. vestibule, nasal passages, and nasopharynx c. ala nasi, vestibule, and ethmoid sinuses C. turbinates, ethmoid sinuses, and nasal passages

B

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? A. speculum B. tongue depressor C. penlight D. tuning fork E. gloves

BCE

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? A. have the child blow the nose to assess drainage B. Reassure the mother that this is common in children C. Inspect the nostrils with an otoscope D. Assess for allergies to antibiotic

C

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? A. heavy alcohol use B. chewing betel nuts C. asthma D. exposure to the sun

C

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? A. self care deficit B. ineffective health maintenance C. Acute Pain D. Hopelessness

C

A client reports experiencing chronic headache after a recent upper respiratory tract infection. On physical examination, the nurse notes tenderness when palpating over the sinuses. Which condition is likely? A. allergic rhinitis B. epistaxis C. acute bacterial sinusitis D. rhinitis medicamentosa

C

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? A. right ptosis B. weak gait C. dysphagia D. facial weakness

C

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? A. C B. K C. B12 D. D

C

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? A. brown spots on the chewing surface of teeth B. enlarged palatine tonsils C. receding and ischemic gums D. Bifid uvula

C

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? A. respiratory infection B. end-stage liver disease C. small bowel obstruction D. diabetic ketoacidosis

C

The client has experienced a stroke and has dysphagia. The nurse knows this is what? A. difficulty talking B. painful swallowing C. Difficulty swallowing D. Lack of a gag reflex

C

The nurse examines the pharynx of a patient and records that the tonsils are touching the uvula. The nurse would grade the tonsils as A. 1+ B. 2+ C. 3+ D. 0

C

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the A. laryngeal sinuses B. sphenoidal sinuses C. maxillary sinuses D. ethmoidal sinuses

C

When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: A. early jaundice can be detected B. sloughing of papillae begins C. cancers often occur D. lesions from loose dentures are found

C

The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion? A. nasal spray can be shared between family members only B. finish the bottle of nasal spray to clear the infection effectively C. administer the nasal spray in a prone position D. overuse of nasal spray may cause rebound congestion

D

A client diagnosed with Sjogren syndrome should be given which instructions? A. blood pressure should be checked frequently B. taking mucus thinning medication can relieve symptoms C. condom use can reduce the risk of transmission D. eye drops and sucking on hard candy may be used to relieve dryness

D

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? a. scrape off the white coating iwtha toothbrush B. apply the prescribed topical antibiotic gel as directed C. Clean mouth and tongue with hydrogen peroxide and water D. Rinse mouth with antifungal medication as prescribed

D

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should A. ask the client if his gums bleed B. document the presence ofa canker sore C. document the presence of herpes simplex D. refer the client for further evaluation

D

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? A. 1+ B. 2+ C. 3+ D. 4+

D

An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result? A. hold the light source below the eyebrow B. lightly tap with fingers over the maxillary sinus C. dim the lights in the room during examination D. instruct the client to remove upper dentures

D