(N125/3) Ears, Nose, Mouth, Throat

Which statement best describes the appearance of a geographic tongue? 1. Bright red with shiny, circular bald areas and pearly borders 2. Slick and shiny with thinned mucosa and a red color 3. Black-brown to yellow in color with elongated filiform papillae 4. Deep furrows and small irregular shaped rows

1 Rationale: A geographic tongue has a pattern of normal coating interspersed with bright red, shiny, circular bald areas with raised pearly borders. The pattern resembles a map and is not a significant finding. A smooth, glossy tongue is slick and shiny with thinned mucosa and looks red. It occurs due to the deficiency of vitamin B 12, folic acid, and iron. A black tongue has elongated filiform papillae and painless overgrowth of mycelial threads of fungus infection. The color varies from black-brown to yellow. Fissured or scrotal tongue has deep furrows that divide the papillae into small irregular rows. The condition occurs in 5% of the general population and in Down syndrome.

The nurse is assessing a patient who reports having lost the sense of smell. Which cranial nerve may be affected in this patient? 1. Cranial nerve I 2. Cranial nerve IX 3. Cranial nerve X 4. Cranial nerve XII

1 Rationale: A patient with loss of smell may have an impaired cranial nerve I, which transmits the sense of smell to the temporal lobe of the brain. The olfactory receptors merge into the olfactory nerve, or cranial nerve I. Cranial nerve IX is the glossopharyngeal nerve, which senses pain, touch, and temperature. Cranial nerve X is the vagus nerve that controls the pharynx, larynx, esophagus, trachea, bronchi, some portion of the heart, and palate. Cranial nerve XII is the hypoglossal nerve that controls tongue movement.

Which group of individuals has a higher risk of middle ear infections? 1. Infants 2. Adolescents 3. Adults 4. Geriatrics

1 Rationale: The Eustachian tube of the infant is shorter, wider, and straight than in other age groups. This enables microorganisms to enter the middle ear through the nasopharynx more easily, which means infants are more prone to middle ear infections. In adults, adolescents, and geriatric patients, the Eustachian tube is long, narrow, and slightly curved so microorganisms may not pass as easily into the middle ear and cause infection.

The nurse is assessing the buccal mucosa of a patient and documents the presence of aphthous ulcers. What did the nurse observe during the examination? 1. A small, round, "punched-out" ulcer with a white base surrounded by a red halo. 2. Small blue-white spots with irregular red halo scattered over mucosa opposite the molars. 3. Chalky white, thick raised patch with well-defined borders. 4. White, cheesy, curd-like patch on the buccal mucosa and tongue.

1 Rationale: An aphthous ulcer, or common "canker sore," is a vesicle at first and then a small, round, "punched-out" ulcer with a white base surrounded by a red halo. Koplik spots are an early sign of measles. They appear as small blue-white spots with an irregular red halo scattered over mucosa opposite the molars. Leukoplakia is a chalky white, thick, raised patch with well-defined borders. The lesion does not scrape off and often occurs on the lateral edges of the tongue. Candidiasis is a white, cheesy, curd-like patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily.

During the dental examination of a patient, the nurse notes a nontender, fibrous nodule on the gum between the teeth. What term should the nurse use to document this condition? 1. Epulis 2. Malocclusion 3. Meth mouth 4. Edentulism

1 Rationale: An epulis is a nontender fibrous nodule of the gum emerging between the teeth. It is an overgrowth of the vascular granulation tissue. Malocclusion occurs when the upper and lower jaws are not in alignment, causing chewing problems or speech disfluency. Meth mouth is a condition caused by methamphetamine abuse. The patient has extensive dental caries, gingivitis, tooth cracking, and loss of tooth. Edentulism refers to the loss of teeth either due to aging or decay.

Which chromosome helps determine the presence of wet or dry cerumen in a newborn? 1. Chromosome 16 2. Chromosome 17 3. Chromosome 18 4. Chromosome 19

1 Rationale: Chromosome 16 contains a gene that helps determine whether a newborn will have a dry or a wet cerumen. Chromosomes 18, 19, and 17 do not contain genes that affect the cerumen.

The nurse documents the presence of Epstein pearls in a 1-month-old infant. What does this finding indicate? 1. Presence of small retention cysts 2. Presence of white glistening teeth 3. Presence of abrasions from sucking 4. Presence of lacerations on the gums

1 Rationale: Epstein pearls are a normal finding in newborns and infants. They are small, whitish, glistening, pearly papules along the median raphe of the hard palate and on the gums. They are actually small retention cysts, which disappear in the first few weeks of birth. Epstein pearls are not teeth, but look like white glistening teeth. Bednar aphthae are abrasions from sucking. They are traumatic areas or ulcers on the posterior hard palate on either side of the midline. Bruising or lacerations on the gums or buccal mucosa of the infant indicate child abuse from forceful feeding of a bottle or spoon.

The nurse is examining the teeth of a patient. What is considered a normal finding? 1. The upper teeth rest directly on the lower teeth. 2. The teeth are brown, straight, and unevenly spaced. 3. The lower incisors slightly override the upper incisors. 4. The tooth surface appears to have been ground down.

1 Rationale: In a normal dental alignment, the upper teeth rest directly on the lower teeth. This is the normal occlusion in the back. Teeth may be discolored or brown following an excessive use of fluoride. Normally, the upper incisors slightly override the lower incisors in the front of the mouth. Bruxism is a condition that causes the patient to grind the teeth unconsciously. This leads to erosion of the tooth surface.

The nurse is caring for an elderly patient diagnosed with presbycusis. Which intervention would be most beneficial for the patient? 1. Providing hearing aids to the patient 2. Instilling antibiotic solutions into the patient's ear 3. Inserting tympanostomy tubes into the patient's ear 4. Irrigating the patient's ear canal with a warm solution

1 Rationale: Presbycusis is an age-related hearing loss, which is caused by degeneration of the auditory nerve in the inner ear that consequently results in sensorineural hearing loss. Therefore, the nurse would provide hearing aids to improve hearing in the patient. Antibiotics help alleviate the symptoms of ear infection, but do not prevent degeneration of the nerve. Tympanostomy tubes facilitate the outflow of the fluid accumulated in the middle ear, but do not help prevent nerve degeneration. Irrigating the ear canal with a warm solution helps flush out the impacted cerumen in the middle ear and prevents conductive hearing loss, but this intervention does not help prevent degeneration of the nerve caused by aging.

The nursing instructor is teaching about presbycusis. Which statement by the student nurse indicates effective learning? 1. "It is the sensorineural loss that occurs with aging." 2. "It occurs due to logging of water in the ear after swimming." 3. "It is the inflammation in the ear that occurs with obstruction of the eustachian tube." 4. "It occurs in neonates who are fed by bottle during the first three months of age."

1 Rationale: Presbycusis is the progressive sensorineural loss due to nerve degradation in the inner ear. It most commonly occurs with aging. Presbycusis is not associated with logging of water in the ear, obstruction of the eustachian tube, or absence of breastfeeding in the first three months. Logging of water in the ear results in swimmer's ear, or otitis externa, due to the presence of excessive moisture in the ear. The presence of inflammation in the ear indicates that the patient has otitis media. It is caused by an obstruction in the eustachian tube. Neonates who are not breastfed for the first three months of age have low immunity and have a higher risk of developing otitis media, but not presbycusis.

After reviewing the diagnostic reports of a patient with hearing impairment, the nurse concludes that the patient has sensorineural hearing loss. Which finding supports the nurse's conclusion? 1. Presence of cranial nerve VIII damage 2. Presence of foreign bodies in the ear 3. Presence of pus or serum in the middle ear 4. Presence of perforated tympanic membrane

1 Rationale: Sensorineural hearing loss is caused by damage to cranial nerve VIII. This results in hearing impairment, because there is an impaired transmission of the impulses produced by sound. Foreign objects affect the external ear, but would not cause sensorineural hearing loss. Pus in the middle ear and perforated tympanic membranes may result in conductive hearing loss due to the dysfunction of the middle ear. Because these conditions do not impair the transmission of impulses, they do not cause sensorineural hearing loss.

Which part of the ear connects the middle ear to the nasopharynx? 1. Eustachian tube 2. Semicircular canals 3. Tympanic membrane 4. External auditory canal

1 Rationale: The eustachian tube connects the middle ear to the back of the nose and the upper part of the throat. The semicircular canals are the three tubes present in the inner ear. The tympanic membrane is also called the eardrum. It separates the external and the middle ear. The external auditory canal is a long tube that leads to the tympanic membrane.

A patient reports spinning and whirling sensations to the nurse. Which part of the ear does the nurse suspect to be damaged in this patient? 1. Labyrinth 2. Ear ossicles 3. Eustachian tube 4. External auditory canal

1 Rationale: The labyrinth is a part of the inner ear, consisting of the organs that aid in hearing and maintaining body balance. If the labyrinth is damaged in a patient, it results in staggering gait, along with spinning and whirling sensations. Ear ossicles help in the conduction of sound vibrations to the inner ear and also protect the inner ear from loud sounds. Damage to ear ossicles may result in loss of hearing. The eustachian tube helps in equalization of air pressure on both sides of the tympanic membrane. If the eustachian tube is damaged, it results in muffled sounds, earache, and a feeling of fullness in the ears. The external auditory canal consists of wax glands, which secrete wax that acts as a barrier and prevents the invasions of foreign bodies into the ear.

Which statement accurately describes the parotid gland? 1. It is a salivary gland. 2. It is located behind the ear. 3. It is the size of a walnut. 4. It secretes into the perinasal sinuses.

1 Rationale: The mouth contains three pairs of salivary glands. The parotid gland is the largest salivary gland and it secretes saliva through the Stensen's duct. This duct runs forward to open on the buccal mucosa opposite the second molar. The perinasal sinuses are not involved with the parotid gland. The parotid gland lies within the cheeks in front of the ear, extending from the zygomatic arch down to the angle of the jaw. The submandibular gland is the salivary gland that is the size of a walnut.

What action should the nurse take during an otoscopic examination of an adult patient? 1. Pull the auricle up and back. 2. Pull the auricle downward. 3. Touch the speculum to the bony surface. 4. Tilt the head of the patient towards left.

1 Rationale: The nurse should pull the auricle up and back for an adult or an older child. This helps straighten the S-shape of the canal. In case of an infant or a child younger than 3 years of age, the nurse should pull the auricle downward. The nurse should insert the speculum slowly and carefully along the axis of the canal. The nurse should avoid touching the inner "bony" section of the canal wall. It is covered by a thin epithelial layer and is sensitive to pain. The nurse should also tilt the patient's head slightly away toward the opposite shoulder. This method brings the obliquely sloping eardrum into better view.

The nurse is teaching a mother about preventing baby bottle tooth decay. Which statement by the nurse is appropriate? 1. "Do not put your baby in the crib with a bottle of milk." 2. "Bottle-feeding causes decay of the lower front teeth." 3. "Do not bottle-feed after your baby is 2 years old." 4. "Bottle-feeding delays the arrival of permanent teeth."

1 Rationale: The nurse should teach the mother not to put the baby to bed with a bottle of milk, because it causes destruction of the deciduous teeth. Liquid pools in the upper front teeth when the baby is put to bed with a bottle of milk or juice. Bacteria in the mouth act on the carbohydrates in the liquid to form metabolic acids. These acids break down the tooth enamel and destroy its protein. The baby should not be bottle-fed past the age of one year to prevent the risk of losing deciduous teeth. Bottle-feeding does not delay the arrival of permanent teeth.

Which statement best describes a tonsillar tissue? 1. Tonsillar tissue enlarges until puberty and then shrinks. 2. Tonsillar tissue is found in the oropharynx. 3. Tonsillar tissue is made up of muscles. 4. Tonsillar tissue has no blood vessels.

1 Rationale: Tonsillar tissue enlarges during childhood until the time of puberty and then involutes. The pharyngeal tonsils, also called adenoids, are located in the nasopharynx. Tonsillar tissue is made up of lymphoids. Like all tissue, tonsillar tissue has blood vessels.

The nurse is assessing a pregnant patient who is in the seventh week of gestation. After reviewing the patient's laboratory and diagnostic reports, the nurse suspects the fetus is at risk of hearing impairment. Which finding supports this assumption? 1. The patient has rubella infection. 2. The patient has vitamin A deficiency. 3. The patient has high estrogen levels. 4. The patient has high platelet count.

1 Rationale: Usually, the internal ears of the fetus develop during the fifth week of gestation. If the mother has rubella infection during the first trimester of the pregnancy, the virus could invade the fetus and impair the development of the internal ear, causing hearing impairment later. Vitamin A is essential for vision but not for hearing, so vitamin A deficiency would not cause hearing impairment in the fetus. An increase in estrogen levels is a normal finding during pregnancy, and this would not increase the risk of hearing impairment in the fetus. A high platelet count increases the risk of clotting, but not hearing impairment in the fetus.

Which conditions are likely to affect the speech of a patient? 1. Bifid uvula 2. Ankyloglossia 3. Macroglossia 4. Fissured tongue 5. Geographic tongue

1, 2, 3 Rationale: Bifid uvula may affect speech development because it prevents necessary air trapping, which is useful for speech. The uvula looks partly severed and may indicate a submucosal cleft palate. Ankyloglossia or a short lingual frenulum can limit the protrusion of the tongue and impair speech development. The tongue has limited mobility and affects speech (pronunciation of a, d, n). Macroglossia or enlarged tongue may protrude from the mouth, causing an impaired speech development. A fissured tongue is the development of deep furrows that divide the papillae into small irregular rows. It occurs with age and also in patients with Down syndrome. However, it does not cause speech impairment. A geographic tongue has a pattern of normal coating interspersed with bright red, shiny, circular bald areas caused by atrophy of the filiform papillae, with raised pearly borders. It does not affect the speech.

The nurse is preparing to do a physical examination of a patient's nose. What equipment should the nurse gather to complete this assessment? 1. Penlight 2. Otoscope 3. Speculum 4. Gauze pads 5. Tongue blades

1, 2, 3 Rationale: The nurse should gather a penlight, otoscope, and speculum for a nasal examination. A penlight is used to examine the nasal septum. An otoscope is used to examine the nasal cavity. A short, wide-tipped nasal speculum is attached to the otoscope. This apparatus is used to examine the nasal cavity. Gauze pads may be used for holding the tongue during the examination of the tongue. Tongue blades may be used to depress the tongue or retract structures while examining the mouth cavity.

The nurse is assessing a young patient who uses smokeless tobacco (SL-T). What are the health risks that the nurse should discuss with the patient? 1. Oral cancer lesions 2. Lower sperm count 3. Bleeding of the gums 4. Myocardial infarction 5. Altered sense of taste

1, 2, 4 Rationale: Chewing tobacco, inhaling snuff, and spitting tobacco are the methods in which SL-T is used. Chewing tobacco and holding tobacco in the mouth leads to oral cancer. The use of tobacco leads to hypertension and can in turn lead to a myocardial infarction. It is also known to decrease sperm count and cause sterility. Chewing tobacco may not cause bleeding gums. Bleeding gums may be caused by poor dental hygiene or gingivitis. Tobacco does not alter the sense of taste; a decrease in taste buds with age can lead to altered sense of taste.

What are the likely causes of epistaxis in a patient? 1. Vigorous nose blowing 2. Continuous nose picking 3. Presence of nasal polyps 4. Presence of foreign body 5. Occurrence of common cold

1, 2, 4 Rationale: Epistaxis is bleeding from the nose. The most common site of nosebleed is the Kiesselbach plexus, which may be injured due to vigorous nose blowing. Bleeding from the anterior septum is a common occurrence following continuous nose picking. Children are likely to insert foreign bodies in the nares and cause trauma, which can also lead to epistaxis. Nasal polyps are smooth, gray nodules that may be caused by chronic allergic rhinitis. Nasal polyps or the common cold do not cause epistaxis unless the patient has been blowing and picking the nose vigorously.

The nurse is examining the anterior structures a patient's mouth. In which conditions may the nurse find cherry-red lips? 1. Ketoacidosis 2. Aspirin poisoning 3. Shock and anemia 4. Hypoxemia and chilling 5. Carbon monoxide poisoning

1, 2, 5 Rationale: The patient with diabetic ketoacidosis has a sweet, fruity acetone-like breath and cherry-red lips. Acidosis from aspirin poisoning also causes cherry-red lips. The patient suffering from carbon monoxide poisoning will present with cherry red lips. In fair-skinned people, circumoral pallor occurs with shock and anemia. Cyanosis is observed in patients with hypoxemia and chills.

What should the nurse teach the patient about the changes in the nose and mouth during pregnancy? 1. Increased risk of nosebleeds 2. Increased risk of gum bleeds 3. Decrease in salivary secretion 4. Weakening of dental enamel 5. Increased occurrence of nasal stuffiness

1, 2, 5 Rationale: There is increased vascularity in the upper respiratory tract during pregnancy. The nurse should tell the patient about the increased possibility of experiencing nosebleeds. During pregnancy, the gums are hyperemic and softer than normal so the gums may bleed with normal brushing. Increased vascularity also causes nasal stuffiness. Weakness of tooth enamel and decrease in salivary secretion are not observed during pregnancy. The aging adult experiences dental changes that include abrasions of the tooth surfaces.

Which changes in the elderly patient should the nurse document as age-related alterations? 1. The nose appears to be larger and more prominent. 2. The upper teeth are more likely to have dental caries. 3. The mouth and lips have a purse-string appearance. 4. The teeth appear longer and develop vertical cracks. 5. The posterior hard palate may have Bednar aphthae.

1, 3, 4 Rationale: The nose of the elderly patient may appear to be larger and more prominent due to the loss of subcutaneous fat. The elderly patient may be edentulous, causing the mouth and lips to fold in, giving it a purse-string appearance. What teeth remain may appear longer as the gum margins recede.A lifetime of exposure to extreme temperatures can cause the surface of the incisors to develop vertical cracks. Infants who are put to bed with a bottle of milk or sweetened drinks are likely to develop caries in the upper teeth. Infants develop Bednar aphthae, which are trauma or ulcers occurring on the posterior hard palate from sucking.

What are the functions of the tongue? 1. Cleans the teeth 2. Lubricates food bolus 3. Enables taste sensation 4. Helps with speech formation 5, Cleans and protects the mucosa

1, 3, 4 Rationale: The tongue is able to change its shape and position within the mouth, making it a tool that helps to clean the teeth. There are microscopic taste buds in the papillae at the back and along the sides of the tongue and on the soft palate, which enable the tongue to differentiate between different tastes. The ability of the tongue to change its shape and position also allow the formation of speech. The mouth contains three pairs of salivary glands that secrete saliva. The saliva is the clear liquid that lubricates the food bolus to enhance digestion. The saliva also cleans and protects the mucosa.

When assessing a patient for furuncles, what signs does the nurse look for? 1. Darkened red and swollen nasal turbinates 2. Small, reddened boils on the skin or mucosa 3. Purulent discharge with inflamed mucosa 4. Smooth, pale gray nodules on the mucosa

2 Rationale: Furuncles are small, red boils on the skin or mucosa. Furuncles appear reddened and swollen and are quite painful. The patient with acute rhinitis will have dark red and swollen turbinates. The patient will also have purulent discharge with inflamed mucosa at a later stage. Nasal polyps appear as smooth, pale gray, stalked nodules on the mucosa; nasal polyps are commonly caused by chronic allergic rhinitis.

What are the functions of the paranasal sinuses? 1. Produce needed mucus 2. Warm the inhaled air 3. Lighten the skull bones 4. Filter dust and bacteria 5. Vibrate to produce sound

1, 3, 5 Rationale: Paranasal sinuses provide mucus that drains into the nasal cavity. Paranasal sinuses are air-filled pockets located within the cranium that help lighten the weight of the skull bones. Additionally, they act as resonators by vibrating to produce sound. The nasal mucosa contains a rich supply of blood vessels that are responsible for warming inhaled air. The anterior edge of the nasal cavity is lined with nasal hair, and the rest of the nasal cavity is lined with a blanket of ciliated mucous membrane. The mucous blanket filters out dust and bacteria.

Which findings are causes of concern to the nurse while examining a patient's gums? 1. There is a dark line on the gingival margins. 2. The gums look coral with a stippled surface. 3. The gums bleed even with a slight pressure. 4. The gum margins at the teeth are well defined. 5. There are crevices between the teeth and gums.

1, 3, 5 Rationale: The presence of a dark line on the gingival margin indicates lead or bismuth poisoning. If the gums bleed with application of slight pressure, the patient has gingivitis. Crevices or spaces between the teeth and gums can lead to accumulation of debris. Normally, the gums look pink or coral with a stippled or dotted surface. The gum margins at the teeth must be tight and well defined to prevent formation of pockets of debris.

The nurse identifies macroglossia during the assessment of a patient. Patients with which conditions are likely to have macroglossia? 1. Acromegaly 2. Malnutrition 3. Heavy smokers 4. Hypothyroidism 5. Mental retardation

1, 4, 5 Rationale: An enlarged tongue or macroglossia is identified in patients with acromegaly, hypothyroidism, and mental retardation. The tongue is enlarged and may protrude from the mouth, causing impaired speech. A small tongue occurs with dehydration. Heavy smokers are likely to develop black tongue from the elongation of filiform papillae and overgrowth of the mycelial threads of fungus infection.

The nurse is examining the mouth of a 20-month-old infant. What is the expected number of deciduous teeth in this infant?

14 Rationale: The child's age in months minus the number 6 should equal the expected number of deciduous teeth. 20 - 6 = 14

What is a normal finding in a 1-year-old infant? 1. The presence of yellow teeth 2. The presence of sucking tubercle 3. The presence of brown upper teeth 4. The presence of short lingual frenulum

2

What is the cause of a peritonsillar abscess? 1. Allergic reaction to pollen 2. Untreated acute pharyngitis 3. Aggravation of a viral infection 4. Chronic use of smokeless tobacco

2 Rationale:

The nurse notices that a patient has a deviated nasal septum. What action should the nurse take when caring for this patient? 1. Notify the primary health care provider. 2. Chart the findings for future reference. 3. Provide supplemental oxygen as needed. 4. Ignore this, because the patient is breathing well.

2 Rationale: A deviated nasal septum looks like a hump or shelf in one side of the nasal cavity. The nurse should document this finding for further reference. Although this is not a condition that must be fixed immediately, it may be useful information for the future if the patient ever requires nasal suctioning or insertion of a nasogastric tube during a hospital stay. The nurse does not need to inform the health care provider, because the finding is not significant. The nurse does not need to arrange supplementary oxygen unless the patient has an obstructed airflow. The nurse must not disregard the finding but should document it for future reference.

During the otoscopic examination of a patient, the nurse sees that the superior part of the patient's eardrum is bright red and bulging. What does the nurse infer from this finding? 1. The patient has skull fracture. 2. The patient has acute otitis media. 3. The patient has chronic otitis media. 4. The patient has a fungal ear infection.

2 Rationale: Acute otitis media is an acute inflammation of the middle ear, which may result in vasodilatation and accumulation of fluid. This may cause a bright red and bulging eardrum. Skull fracture may result in bleeding from the inner ear and may cause a bluish or dark red discoloration of the eardrum. Chronic otitis media is characterized by the presence of a thick, yellow amber-colored eardrum due to severe inflammation and the formation of pus. Fungal ear infections are characterized by the presence of black or white spots on the eardrum.

The nurse is assessing a patient diagnosed with ankyloglossia. What does this condition indicate? 1. The patient is a heavy smoker. 2. The patient has a speech defect. 3. The patient has a B 12 deficiency. 4. The patient has a low level of folic acid.

2 Rationale: Ankyloglossia or tongue-tie is a condition in which the patient has a short lingual frenulum. This fixes the tongue tip to the floor of the mouth and gums. It is a congenital defect leading to defects in pronunciation. Black hairy tongue is a condition found in heavy smokers. It is identified by the presence of filiform papillae and painless overgrowth of the mycelial threads of fungus infection on the tongue. Atrophic glossitis or smooth, glossy tongue is a condition in which the mucosa is thinned and looks red due to decreased papillae. It is a result of the deficiency of vitamin B 12, folic acid, and iron; this patient has pernicious anemia and folic acid deficiency.

The nurse is examining the mouth of a patient and notices a musty breath odor. What is the most likely cause of this finding? 1. Uremia 2. Liver disease 3. Dehydration 4. Dental infection

2 Rationale: Breath odor or halitosis is common and usually has a local cause. However, sometimes it may indicate a systemic disease. A musty breath odor occurs with liver disease. Ammonia-like breath odor occurs with uremia. Diabetic ketoacidosis in patients or dehydration and malnutrition in children cause a sweet, fruity, acetone breath odor. Dental infection gives rise to a foul, fetid odor in breath.

The nurse is assessing a child with unilateral mucopurulent drainage from the nose. What is the most probable diagnosis? 1. Occurrence of sinusitis 2. Presence of foreign body 3. Onset of allergic rhinitis 4. Posterior septum injury

2 Rationale: Children may insert small objects into their nostrils, which may remain unnoticed until there is a mucopurulent, foul-smelling drainage from the nostril. Sinusitis is the inflammation and infection of the sinuses. The patient will have bilateral mucopurulent drainage, nasal obstruction, facial pain, and loss of sense of smell. Allergic rhinitis presents with clear, watery discharge, itching of the eyes and nose, lacrimation, nasal congestion, and sneezing. The patient with an injury to the posterior septum will have profuse bleeding that is difficult to control.

The nurse is preparing a young child with a cleft lip for surgery. What would be the consequence of delayed treatment? 1. Ear infections 2. Speech difficulty 3. Dental problems 4. Swallowing difficulty

2 Rationale: Early treatment is recommended for children with cleft lip to preserve the functions of speech and language formation. Maxillofacial clefts are congenital deformities of the head and neck. Cleft palate, not cleft lip, may lead to ear infections, dental problems, and difficulty in swallowing due to failure of the fusion of maxillary processes.

After an otoscopic examination, the nurse suspects otitis media in the patient. What observation would support this? 1. Perforated tympanic membrane 2. Fluid behind the tympanic membrane 3. Shiny and translucent tympanic membrane 4. Impacted cerumen blocks the tympanic membrane

2 Rationale: Fluid visible behind the tympanic membrane indicates otitis media. This makes the color of the tympanic membrane amber yellow. If the fluid of the middle ear is infected, it causes acute otitis media. A perforated tympanic membrane or impacted cerumen may cause conductive hearing loss. The tympanic membrane may not be visible by an otoscope if cerumen becomes dry and gets impacted. A shiny and translucent tympanic membrane is a normal finding.

The nurse is assessing a patient who reports feeling like there is a valve that moves in the nose while breathing. What would the nurse expect to find during the examination of the nose? 1. Furuncles 2. Nasal polyps 3. Foreign body 4. Perforated septum

2 Rationale: Nasal polyps are smooth, pale gray nodules, which may be at the end of a stalk. They are overgrowths of the mucosa caused by chronic allergic rhinitis. They may obstruct air passages as they grow larger, causing a feeling of a "valve that moves in the nose" while breathing. Furuncles are small boils that are located in the skin or mucous membranes and are painful and easily spread by trauma. A foreign body may cause an obstruction to the passageway, but may not move as the patient breathes. A perforated septum is a hole in the cartilaginous part of the septum caused by chronic infection or trauma from nose picking.`

The nurse shines a light on the roof of the patient's mouth to examine the palate. Which finding would need further investigation? 1. The uvula appears to be split into two parts. 2. The anterior hard palate is muddy yellow. 3. The hard palate has a nodular bony ridge. 4. The posterior soft palate easily moves up.

2 Rationale: Normally, the anterior palate is white with irregular transverse rugae. If the anterior palate appears yellow or muddy yellow, it is an indication of jaundice and needs further investigation. The uvula normally looks like a fleshy pendant hanging in the middle. A bifid uvula or uvula that appears to be split into two is normal in American Indians. Torus palatinus is a nodular bony ridge down the middle of the hard palate and is a normal variation. It is a benign growth that appears after puberty in American Indians, Inuits, and Asians. The posterior soft palate is normally pink, smooth, and upwardly movable.

Which part of the ear comprises the organs that aid in hearing and maintaining the equilibrium? 1. Malleus 2. Labyrinth 3. Tympanic membrane 4. External auditory canal

2 Rationale: The labyrinth is part of the inner ear that comprises the vestibule, the semicircular canals, and the cochlea. The cochlea aids in hearing, whereas the vestibule and semicircular canals aid in maintaining balance. Therefore, the labyrinth comprises the organs that aid in hearing and maintaining equilibrium. The malleus is one of the earbones of the middle ear that transmit sound vibrations from the tympanic membrane to the incus. The tympanic membrane is a part of the external ear that transmits sound from outside to the ossicles of the middle ear. The external auditory canal is a part of the external ear. It consists of wax glands that secrete cerumen and protect the ear from foreign bodies.

What is the characteristic feature of the submandibular salivary gland? 1. It is situated in both of the cheeks in front of each ear. 2. It contains ducts that open at each side of the frenulum. 3. It is an almond-shaped gland with many small openings. 4. It goes from the zygomatic arch to the angle of the jaw.

2 Rationale: The mouth contains three pairs of salivary glands. The submandibular gland lies beneath the mandible at the angle of the jaw. Its ducts are called the Wharton ducts and run up and forward to the floor of the mouth and open at either side of the frenulum. The largest salivary gland is the parotid gland, which lies within the cheeks in front of the ear. The submandibular salivary gland has a size similar to that of a walnut, whereas the sublingual gland, which is the smallest, is almond-shaped. The sublingual gland lies within the floor of the mouth and has many small openings along the sublingual fold of the tongue. The parotid gland extends from the zygomatic arch down to the angle of the jaw.

The nurse is examining the mouth of an African American patient. Which finding is a cause for concern? 1. The presence of noticeable patchy hyperpigmentation on the cheek 2. The presence of a white cheesy curd-like patch that can be scraped off 3. The presence of small white papules seen on the mucosa of the cheek 4. The presence of a milky, bluish-white patch along the buccal mucosa

2 Rationale: The nurse must examine the presence of white cheesy curd-like patch on the tongue and buccal mucosa. If it rubs off leaving a clear, raw denuded surface, it is an oral infection referred to as thrush or candidiasis. Although the cheeks are normally pink, smooth, and moist, it is common and normal to find patchy hyperpigmentation in African Americans. Fordyce granules are small, isolated, white or yellow papules on the mucosa of the cheek, tongue, and lips. These are not a cause for concern, because they are painless sebaceous cysts that are not significant. The presence of leukoedema or a large milky, bluish-white patch along the buccal mucosa in African Americans is a normal finding. The bilateral patches may disappear as the cheeks are stretched and are not a cause for concern.

The nurse is caring for a patient with an infection at the lip-skin junction caused by the herpes simplex virus (HSV-1). What should the nurse teach the patient? 1. The pustules will heal in 30 days. 2. The infection is highly contagious. 3. The infection is unlikely to recur. 4. The lesion dries in sun exposure.

2 Rationale: The nurse should teach the patient to refrain from direct contact with others because the infection is highly contagious. Cold sores evolve into pustules that rupture, weep, crust, and heal in 4 to 10 days. The infection often recurs at the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, and allergy.

The nurse is assessing a patient with severe cold and nasal congestion. Which sinuses will the nurse assess during a physical examination? 1. Ethmoid sinuses 2. Maxillary sinuses 3. Sphenoid sinuses 4. Paranasal sinuses

2 Rationale: The nurse will assess the maxillary sinuses during a physical examination. These sinuses are located in the maxilla or cheekbone along the side walls of the nasal cavity. The ethmoid, sphenoid, and paranasal sinuses cannot be examined physically. The ethmoid sinuses are smaller and lie deep between the orbits. The sphenoid sinuses lie deep within the skull in the sphenoid bone. The paranasal sinuses are air-filled pockets within the cranium.

The nurse is examining the throat of a patient. What does the nurse document as a normal finding? 1. The tonsils are bright red in color and swollen. 2. The tonsils have crypts on their rough surfaces. 3. The tonsils are covered by a white membrane. 4. The tonsils have large white spots or exudates.

2 Rationale: The oval, rough-surfaced tonsils lie behind the anterior tonsillar pillar. It is normal to find the rough surface peppered with indentations, or crypts. The tonsils are normally the same pink in color as found on the oral mucosa. Bright red and swollen tonsils indicate acute infection. A white membrane may cover the tonsils if the patient has infectious mononucleosis, leukemia, or diphtheria. During an acute infection, the tonsil may have large white spots or exudates.

Which finding does the nurse expect in a patient with acute tonsillitis? 1. Presence of indentations on the pink tonsils 2. Presence of exudate or white spots on the tonsils 3, Presence of white cellular debris in the crypts 4, Presence of white membrane on the tonsils

2 Rationale: The patient with acute tonsillitis will have bright red and swollen tonsils with exudate or white spots. Normally, tonsils are pink like the oral mucosa, with their surfaces peppered with indentations or crypts. These crypts may contain white cellular debris in some people; however, it is not an indication of an infection. A white membrane covering the tonsils may accompany infectious mononucleosis, leukemia, or diphtheria.

During an assessment a patient reports watery nasal secretions, pale turbinates, and sneezing. What diagnosis is likely for this patient? 1. Epistaxis 2. Allergic rhinitis 3. Rhinorrhea 4. Sinusitis

2 Rationale: The symptoms of seasonal allergic rhinitis are rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing. Turbinates are usually pale and their surface looks smooth and glistening. Common allergens are dust mites, pollens, molds, and so forth. Epistaxis is the bleeding from the anterior nasal septum. It is rarely severe and can be easily controlled. Causes include nose picking, forceful coughing or sneezing, fracture, coagulation disorder etc. Rhinorrhoea or runny nose is a common symptom of allergy. During this condition, the nasal cavity is filled with a significant amount of mucus. Sinusitis occurs due to inflamed infected sinus areas following upper respiratory infection. It is most often viral in origin.

While assessing the throat of a child, the nurse documents the tonsils as 3+. What does this indicate? 1. Tonsils are just visible 2. Tonsils touch the uvula 3. Tonsils touch one another 4. Tonsils are free of infection

2 Rationale: Tonsils are graded according to their size. Tonsils are graded as 3+ when they are enlarged and touching the uvula. It indicates an acute infection. Normally, 1+ tonsils are visible and seen in healthy people. Tonsils that touch one another are graded as 4+ and signify acute infection. Tonsils that are infected 2+ are larger. It is normal to find 1+ and 2+ tonsils in children because the lymphoid tissue is proportionately enlarged until puberty. In adults, 2+ can indicate an infection.

The nurse is performing an otoscopic examination in an adult patient. What would the nurse do to straighten the patient's ear canal during the test? 1. Pull the patient's pinna straight out 2. Pull the patient's pinna up and back 3. Leave the patient's ear undisturbed 4. Pull the patient's pinna down and back

2 Rationale: While performing the otoscopic examination in an adult patient, the nurse should pull the patient's ear up and back, which helps straighten the S-shaped ear canal. Pulling the ear straight out or leaving it undisturbed does not straighten the ear canal, and could hinder the examination. Pulling the patient's pinna down and back is only effective on children under the age of three, because their ear canals are much shorter.

When examining an elderly patient, what changes in the structure and function of the nose would the nurse expect to find? 1. The nasal hair becomes more flexible. 2. The nose appears to be more prominent. 3. The olfactory nerve fibers may increase. 4. Nasal stuffiness occurs more frequently.

2 Rationale; The nose of the aging adult becomes more prominent because of a loss of subcutaneous fat. The nasal hair loses its flexibility and grows coarser and stiffer. This may cause itching and sneezing, and the air may not be filtered well. The aging adult begins to lose the sense of smell as olfactory nerve fibers may decrease. Nasal stuffiness is not related to aging; it may occur with increased vascularity.

Which are the bones of the middle ear? 1. Cochlea 2. Incus 3. Malleus 4. Stapes 5. Vestibule

2, 3, 4 Rationale: The middle ear contains three ear bones, or auditory ossicles. These are the malleus, incus, and stapes. The cochlea is the part of the inner ear that contains the central hearing apparatus. It is not an ear bone. The vestibule of the ear is an oval cavity in the middle of the bony labyrinth; it is located in the inner ear, not the middle ear.

The nurse is examining a patient with gingivitis. What are the causes that lead to this condition? 1. Treatment of leukemia 2. Poor dental hygiene habits 3. Poor ingestion of vitamin C 4. Changes of hormone levels 5. Use of phenytoin (Dilantin)

2, 3, 4 Rationale: The patient with gingivitis has red, swollen gums that bleed easily. The gingival tissue is desquamated, exposing the roots of the teeth. Gingivitis is caused due to poor dental hygiene or vitamin C deficiency. Changing hormone levels can cause gingivitis during puberty and pregnancy. Gingival hyperplasia is painless enlargement of the gums, sometimes overreaching the teeth. It often occurs in patients with leukemia. Gingival hyperplasia is also caused by the long-term therapeutic use of phenytoin (Dilantin).

The nurse identifies malocclusion while examining dentition in an elderly patient. What is the effect of this condition on the patient? 1. Abrasions of the tooth surfaces 2. Possibility of further tooth loss 3. Inability to open the mouth fully 4. Occurrence of chronic headaches 5. Erosion of teeth at the gumline

2, 3, 4, 5 Rationale: Loss of teeth can cause the remaining teeth to drift, causing malocclusion. The stress of chewing leads to further loss of teeth. The patient may chew on the temporomandibular joint leading to osteoarthritis, pain, and inability to open the mouth fully. The mandibles and maxilla lose their alignment, and the patient will experience muscle imbalance leading to chronic headaches. The gums begin to recede with age leading to erosion of teeth at the gum line. Abrasions of the tooth surface are a natural occurrence not related to malocclusion.

What interventions should the nurse implement to determine the patency of the nares in a newborn? 1. Inspect each individual naris with a penlight. 2. Observe the newborn for any flaring nares. 3. Suction both nares by using a bulb syringe. 4. Push on the tip of the nose with the thumb. 5. Insert a small lumen catheter into the nares.

2, 3, 5 Rationale: Newborns are nose breathers, and the nurse should determine the patency of the nares immediately after birth. The nurse should observe the newborn for nasal flaring, which is an indication of respiratory distress. The nares may contain amniotic fluid, which should be cleared by suctioning using a bulb syringe. If obstruction is suspected, the nurse should insert a small-lumen (5 to 10 Fr) catheter down each naris to confirm patency.

The nurse should assess for early signs of oral cancer during an oral examination of a patient who uses smokeless tobacco (SL-T). What assessment findings require further investigation? 1. Pain in the throat 2. Difficulty in chewing 3. Leathery white patch 4. Prolonged common cold 5. Restricted jaw movements

2, 3, 5 Rationale: The use of SL-T increases the risk of oral cavity cancer compared to smoking. The nurse should gather subjective data about any difficulty in chewing. The presence of smooth or leathery white patches in the tongue or oral cavity requires further investigation. The nurse should also assess the patient's jaw movements and refer any restrictions in the movement for further investigation. Pain is rarely an early sign of oral cancer. Long-standing common colds are not indications for oral cancer. Having a sore throat for a long duration and the feeling of a lump in the throat are warning signs of throat cancer.

Which actions by the nurse would be indicated during the oral examination of a 2-week-old infant? 1. Let the parent restrain the infant's arms. 2. Save the mouth for the end of the examination. 3. Have the parent hold the infant in his or her lap. 4. Put the infant supine on the examination table. 5. Restrain the infant's arms during examination.

2, 4, 5 Rationale: The oral examination is intrusive and disturbing for the infant. The nurse should save the oral examination for last, along with the ear examination. It is convenient to place the infant supine on the examination table to prevent discomfort and complete the examination quickly. The arms of the infant may be restrained by the nurse during the examination. The older infant or toddler may be placed on the parent's lap with one parent holding down the toddler's arms and securing the toddler's head against the parent's chest.

The nurse is caring for a young child who has inserted a tiny battery into the nostril. What is the impending risk for this patient? 1. It can cause the child to aspirate. 2. The nasal turbinates will swell. 3. The nasal mucosa will become burned. 4. It will stimulate the cough reflex.

3 Rationale: A battery that occludes the nostril is likely to release chemicals in the moist environment. This can lead to burns, necrosis, or perforation. The battery may not be aspirated, but it will obstruct the nostril. The nasal turbinates swell during an episode of rhinitis, but the chemicals released from the battery will not cause rhinitis. The occluded battery is not likely to stimulate the cough reflex.

What is a furuncle? 1. A hard, rounded nodule in the eardrum 2. A small round nodule of the hypertrophic bone 3. A reddened, painful, and infected hair follicle of the ear canal 4. A severe inflammation, swelling, or tenderness of the ear canal

3 Rationale: A furuncle is an abnormality of the ear canal which is characterized by a painful, reddened, and infected hair follicle. Osteoma is associated with the presence of hard, rounded nodules present in the eardrum. Exostosis is characterized by the presence of small round nodules in the hypertrophic bone. Otitis externa is an infection of the external auditory canal. Severe swelling, inflammation, and tenderness of the ear canal result from otitis externa.

After assessing a patient who has been in an accident, the nurse concludes that the patient has a basal skull fracture. Which findings support the nurse's conclusion? 1. The patient has redness in the ear with purulent discharge. 2. The patient has gray-colored, foul odor discharge from the ear. 3. The patient has frank blood and watery discharge from the ear. 4. The patient has reddish-blue discoloration from the ear with ear necrosis.

3 Rationale: An injury to the skull may damage the meninges and blood vessels of the brain, which can result in leakage of cerebrospinal fluid (CSF) and active hemorrhage. Therefore, the patient with basal skull fracture may have frank blood and watery discharge or CSF discharges from the ear. The presence of redness in the ear with purulent discharge indicates that the patient has otitis externa. The presence of gray-colored, foul discharge from the ear indicates that the patient has cholesteatoma, which is caused by continuous growth of tissue in the middle ear. The reddish-blue discoloration of the ear with necrosis indicates that the patient has frostbite.

The nurse is assessing a patient with a monilial infection. What are the causes of this infection? 1. Food allergy 2. Heavy smoking 3. Corticosteroids 4. Stress and fatigue

3 Rationale: Candidiasis, or monilial infection, is a white, cheesy, curd-like patch on the buccal mucosa and tongue. It is caused by the use of antibiotics and corticosteroids. This condition is generally observed in immunosuppressed people. Aphthous ulcers or canker sores are quite painful with a white base surrounded by a red halo; they last for one to two weeks and are associated with food allergy. Leukoplakia is a chalky white, thick, raised patch with well-defined borders occurring on the lateral edges of the tongue. It is firmly attached and does not scrape off. It is caused by heavy smoking and alcohol use. Aphthous ulcers are also caused by stress and fatigue.

After reviewing the medical records of a patient, the nurse finds that the patient has hearing impairment caused by damage to the cranial nerve. Which cranial nerve is damaged? 1. Cranial nerve II 2. Cranial nerve VII 3. Cranial nerve VIII 4. Cranial nerve X

3 Rationale: Cranial nerve VIII is the auditory, or vestibule-cochlear, nerve. This nerve transmits the impulses of sound to the brain and aids in hearing. Damage to this cranial nerve can cause hearing impairment and result in deafness. The optic nerve is the second cranial nerve, which aids in vision. The facial nerve is the seventh cranial nerve, which controls facial expressions. The vagus is the tenth cranial nerve; it controls the heartbeat. Therefore, damage to the second, seventh, or tenth cranial nerves will not result in deafness.

While examining a child's ear, the nurse finds that the child has wet cerumen. Which finding would be consistent with the wet cerumen? 1. The child's cerumen appears flaky. 2. The child has grayish cerumen. 3. The child has honey-colored cerumen. 4. The child's ear canal has thin layer of cerumen.

3 Rationale: Due to variations in chromosome 16, the characteristic features of cerumen vary from one individual to the other and cerumen is classified as dry or wet. Wet cerumen is moist and will be honey brown to dark brown in color. Dry cerumen is flaky, gray colored, and forms a thin mass on the ear canal.

Which finding would the nurse associate with hay fever? 1. The turbinates are reddened and swollen. 2. The patient has pain while bending over. 3. The patient has lacrimation and sneezing. 4. The patient has cheek pain that throbs.

3 Rationale: Hay fever, or seasonal allergic rhinitis, is caused by an allergy to pollen. The patient with hay fever has rhinorrhea, lacrimation, and sneezing. Examination of the oral cavity reveals serous edema and swelling of turbinates, which make them appear pale and smooth. The turbinates appear red and swollen in acute rhinitis. The patient with sinusitis has pain with facial palpation and while bending over. The patient with sinusitis also has dull throbbing pain in the cheek and teeth.

A patient feels pain when the nurse pulls the pinna during assessment. What might be the reason for this pain? 1. Frostbite 2. Keloid 3. Otitis externa 4. Branchial remnant

3 Rationale: Otitis externa, also called swimmer's ear, is an infection of the outer ear, with severe pain upon movement of the pinna and the tragus. Redness and swelling of the pinna may also occur. Although frostbite can cause ear pain for the patient, this condition is marked by reddish-blue discoloration and swelling of the auricle, which cause vesicles or bullae. A keloid is an overgrowth of scar tissue, most commonly at the lobule of the pierced ear. The branchial remnant is the leftover embryologic branchial arch, occurring most often in the preauricular area, in front of the tragus.

The nurse is caring for a patient with erythematous, scaling, shallow, and painful fissures at the corners of the mouth. The patient also has excess salivation. What is the possible diagnosis for this patient? 1. Furuncle 2. Mucocele 3. Stomatitis 4. Carcinoma

3 Rationale: Stomatitis is a Candida infection that can occur at the corners of the mouth. It is characterized by erythematous, scaling, shallow, and painful fissures. The condition is often caused by poorly fitting dentures in edentulous patients. A furuncle is a painful, small, red boil that occurs on the skin or nasal mucosa. A mucocele is a very small, round, well-defined, translucent nodule that contains mucus. It is formed on the floor of the mouth or under the tip of the tongue when a duct of a minor salivary gland is ruptured. The initial carcinoma lesion is round and indurates; it later becomes crusted and ulcerated, with an elevated border. It usually occurs between the outer and middle thirds of the lip.

The nurse is caring for an elderly patient who developed a nosebleed after forceful coughing and sneezing. Which specific part of the nose is likely to bleed in this patient? 1. Middle meatus 2. Nasolacrimal duct 3. Kiesselbach plexus 4. Olfactory receptors

3 Rationale: The Kiesselbach plexus is the most common site of nosebleeds. It is the anterior part of the nasal septum, which has a rich vascular network. This bleeding is rarely severe and can be easily controlled. The sinuses drain into the middle meatus, and the nasolacrimal duct drains tears into the inferior meatus of the nasal cavity. These areas are not likely to bleed. Olfactory receptors for smell are hair cells that lie at the roof of the nasal cavity and are not likely to bleed.

What is the function of the inner ear? 1. It promotes lubrication of the ear. 2. It acts as a barrier against foreign bodies. 3. It helps to maintain the balance of the body. 4. It equalizes air pressure on both the sides of the eardrum.

3 Rationale: The inner ear contains the bony labyrinth, which comprises the parts that aid in hearing and maintaining body balance. The external auditory canal is part of the external ear and consists of wax glands that secrete cerumen to promote the lubrication of the ear. Cerumen acts as a sticky barrier that traps foreign bodies and prevents them from reaching the tympanic membrane. The eustachian tube is part of the middle ear and it equalizes air pressure on both the sides of the eardrum.

The nurse asks a nursing student to list the functions of the nose. Which statement by the student nurse needs correction? 1. "The nasal cavity helps to warm, humidify, and filter the inhaled air." 2. "The inferior meatus of the nose receive tears from the nasolacrimal duct." 3. "The paranasal sinuses in the nasal cavity lighten the weight of the skull bones." 4. "Olfactory messages reach the temporal lobe of the brain through the cranial nerve I."

3 Rationale: The nose is the olfactory receptor responsible for the transmission of smell messages. The paranasal sinuses are air-filled pockets within the cranium and not the nasal cavity. They communicate with the nasal cavity and lighten the weight of the skull bones. The nasal cavity is richly supplied with blood vessels and mucous membranes. These help to warm, humidify, and filter the inhaled air. Tears from the nasolacrimal duct drain into the cleft-like structure, the inferior meatus of the nose. Olfactory receptors for smell merge into the olfactory nerve, cranial nerve I, which transmits to the temporal lobe of the brain.

The nurse is assessing a patient with a history of smoking and alcohol use. What should the nurse specifically assess for when examining the patient's tongue? 1. Examine for any white patches or lesions. 2. Inspect the ventral surface of the tongue. 3. Palpate under the tongue for indurations. 4. Check the U-shaped area under the tongue.

3 Rationale: The nurse should place one hand under the jaw to stabilize the tissue and use a gloved hand to palpate under the tongue to check for indurations. An indurated area may be a mass or lymphadenopathy and must be investigated. This examination is important for any person above the age of 50 or with a history of smoking and alcohol use. The nurse examines the tongue of all patients for white patches or lesions. Lesions that are present for more than two weeks must be investigated. The nurse inspects the ventral and dorsal surfaces of the tongue for all patients. The U-shaped area under the tongue is thoroughly inspected for all patients to check for oral malignancies.

After performing the otoscopic examination of a patient, the nurse concludes that the patient has an infection. Which findings enabled the nurse to reach this conclusion? 1. The presence of pearl gray-colored tympanic membrane 2. The presence of whiter and denser annulus at the periphery 3. The presence of yellow/amber-colored tympanic membrane 4. The presence of the malleus visible behind the tympanic membrane

3 Rationale: The presence of a yellow/amber-colored tympanic membrane indicates otitis media with effusion, which is a middle ear infection. The normal tympanic membrane is shiny, translucent, and pearl gray in color. Usually, the annulus appears white in color and denser at the periphery. Therefore, it does not indicate that the patient has an infection. In a healthy individual, the malleus is visible through the tympanic membrane.

The nurse performs an otoscopic examination on the ear of a patient with mycoplasma pneumonia infection. During the exam the nurse sees that the patient has small vesicles on the eardrum that are filled with blood. Which condition does the nurse expect to find in the patient? 1. Otomycosis 2. Otitis externa 3. Bullous myringitis 4. Cholesteatoma

3 Rationale: The presence of small blood-filled vesicles on the eardrum indicates that the patient has bullous myringitis, which is commonly associated with mycoplasma pneumonia and viral infections. It is characterized by the inflammation of the eardrum and severe pain in the ear. Otomycosis is a fungal infection, which is characterized by the presence of black or white dots on the eardrum or the ear canal. If the size of the patient's ear canal is reduced to one-fourth of its normal size due to severe swelling and inflammation, it indicates otitis externa. If the patient's tympanic membrane appears cheesy and pearly white due to the overgrowth of epidermal tissue in the middle ear or temporal bone, the patient has cholesteatoma.

A patient reports having impaired balance and a tendency to fall down while walking. Which test would the nurse perform in the patient in order to identify the cause of these symptoms? 1. Rinne test 2. Weber test 3. Romberg test 4. Otoacoustic emission (OAE) test

3 Rationale: The vestibular apparatus present in the inner ear is responsible for maintaining body balance. If a patient is unable to maintain body balance and falls down frequently, the nurse may suspect that the patient's vestibular apparatus is not functioning correctly. The Romberg test helps to assess the ability of the vestibular apparatus in maintaining standing balance. Rinne and Weber tests are the tuning fork tests that are used to measure hearing loss. In tuning fork tests, the hearing is measured by air or bone conduction. The otoacoustic emission (OAE) test is used to screen hearing ability in the newborn. Rinne, Weber, and OAE tests are used to evaluate hearing impairment.

The nurse is examining the hearing of an elderly patient using the whisper voice test. Which intervention would the nurse follow to properly administer this test? 1. Whisper a set of three random numbers and letters after the patient covers both ears. 2. Whisper a set of three random numbers and letters while standing in front of the patient. 3. Whisper a set of three random numbers and letters while standing 2 feet behind the patient. 4. Whisper a set of three random numbers and letters while standing 10 feet away from the patient.

3 Rationale: To perform the whisper voice test, the nurse would stand 2 feet behind the patient and whisper a set of three random numbers and letters while the patient holds one ear closed. Then the nurse asks the patient to repeat the numbers and letters. This helps the nurse to assess the hearing ability of the patient and provide appropriate treatment. If the nurse stands in front of the patient and whispers the numbers, the patient may be able to understand them by lip reading. The nurse might thus make an inaccurate assessment that the patient has normal hearing. If the nurse stands 10 feet away and whispers the numbers and letters, even an individual with normal hearing would not be able to hear them. Therefore, the nurse needs to stand closer to the patient. The patient may not be able to hear if both ears are closed so the nurse should inform the patient to close only the ear that is not being assessed.

While assessing a patient, the nurse finds that the patient's ears are 3 cm in length and have a small, painless nodule at the helix. What does the nurse infer from these findings? 1. The patient has microtia and swimmer's ear. 2. The patient has macrotia and swimmer's ear. 3. The patient has microtia and Darwin's tubercle. 4. The patient has macrotia and Darwin's tubercle.

3 Rationale: When a patient has smaller ears, the length of which is less than 4 cm vertically, it indicates that the patient has microtia. The presence of a small painless nodule at the helix is indicative of Darwin's tubercle. It is a congenital variation and is not significant. Therefore, the nurse concludes that the patient has microtia and Darwin's tubercle. If the patient's ears are more than 10 cm in length, then it indicates that the patient has macrotia. Swimmer's ear is also known as otitis externa; it is caused by accumulation of water in the ear. It causes inflammation, earache, and redness. Because the patient does not have symptoms of otitis externa, the nurse does not conclude that the patient has microtia and swimmer's ear. Because the patient's ears are not more than 10 cm long and do not have inflammation and pain, the nurse does not conclude that the patient has macrotia and swimmer's ear. A small painless nodule is present in the patient; thus, the patient has Darwin's tubercle. Because the patient's ears are not more than 10 cm long, the nurse does not conclude that the patient has macrotia.

The nurse is caring for a patient who was in an accident. The nurse notices that the patient has clear, watery drainage from the ear. What is the priority nursing intervention in this situation? 1. Instill 2% acetic acid solution in the patient's ear 2. Instill antibiotic solution into the patient's ear 3. Report to the primary health care provider about the patient 4. Irrigate the patient's ear canal with a warm solution

3 Rationale: When caring for a patient who was in an accident or has trauma, the nurse should carefully monitor the patient to identify the internal injuries. If a patient has a clear, watery drainage from the ear, it indicates that the patient has cerebrospinal fluid drainage due to a basal skull fracture, which requires immediate treatment to prevent further damage. Therefore, the nurse should report to the primary health care provider immediately. Instilling 2% of acetic acid solution helps kill microorganisms. It does not help prevent cerebrospinal fluid drainage. Antibiotic solutions help prevent ear infections, but not prevent cerebrospinal fluid drainage. Irrigation of ear canal with warm solution helps remove cerumen from the ear canal, but does not stop the watery drainage from the ears.

While examining the nasal cavity of a patient, the nurse shines the light into one naris and notices the light from the penlight is shining into the other naris. What does this indicate? 1. Loss of blood from the septum 2. Deviation noted in the septum 3. Presence of a perforation in the septum 4. Presence of a congenital bony septum

3 Rationale: When the nasal septum is perforated, the nurse can see the light from the penlight shine from one naris through to the other. Such a perforation may occur from cocaine use, among other reasons. A bleeding septum indicates epistaxis, which usually occurs in the anterior septum. A deviated septum looks like a hump or shelf in one of the nasal cavities. It is a common occurrence and not significant if the air flow is not obstructed. Choanal atresia is a congenital disorder in which a bony septum blocks the nasal cavity and the pharynx.

The nurse needs to assess the posterior pharyngeal wall of a patient whose gag reflex is easily triggered. What should the nurse do to prevent discomfort in the patient? 1. Depress the tongue at the halfway point using a tongue blade. 2. Use the tongue blade to push down at the tip of the tongue. 3. Allow the patient to depress the tongue with the tongue blade. 4. Ask the patient to lower the tongue without a tongue blade. 5. Use the tongue blade to depress the tongue slightly off-center.

3, 4, 5 Rationale: In some patients, the gag reflex is easily triggered. The nurse can allow the patient to depress the tongue with a tongue blade. Some patients are capable of lowering their tongue. The nurse can allow the patient to depress the tongue without a tongue blade. The nurse can also use the tongue blade to depress the tongue slightly off-center. This action does not elicit a gag reflex. The nurse can depress the tongue halfway using a tongue blade, but it may elicit a gag reflex and cause discomfort. If the tongue blade is used to depress or push the tip of the tongue, the tongue humps up in the back, blocking the view.

The nurse is assessing a patient's tongue for color, characteristics, and moisture. Which findings would be normal during the assessment? 1. The patient is drooling a lot. 2. Saliva builds up in the mouth. 3. The dorsal surface feels rough. 4. The tongue is pink and even. 5. The ventral surface is smooth.

3, 4, 5 Rationale: The nurse examines the tongue using gloves and a gauze pad to hold it properly. The dorsal surface of the tongue is rough from the papillae, which contain microscopic taste buds. The tongue is a mass of striated muscles and is normally pink and even. The ventral surface of the tongue is smooth and shiny and has prominent veins. Drooling occurs when excessive saliva accumulates in the mouth. Excessive saliva and drooling occur with gingivostomatitis and neurologic dysfunction.

After examining the tympanic membrane of a patient, the nurse concludes that the patient is normal and does not have hearing impairment. Which finding supports the nurse's conclusion? 1. Presence of slightly retracted tympanic membrane 2. Presence of white dots on the tympanic membrane 3. Presence of air bubbles on the tympanic membrane 4. Presence of pearly gray-colored tympanic membrane

4 Rationale: According to research, the tympanic membrane of healthy individuals appears shiny and translucent with a pearly gray color, so this finding indicates that the patient is normal and does not have any risk of hearing impairment at present. Presence of obstruction in the eustachian tubes may create a negative pressure in the ear that causes retraction of the tympanic membrane, which can result in hearing impairment. The presence of white dots on the tympanic membrane indicates that the patient has a fungal infection. The presence of air bubbles on the tympanic membrane is a characteristic symptom of otitis media with effusion, which is not a normal finding.

After completing the assessment, the nurse suspects that the patient has vertigo. What may be the cause of this finding? 1. The patient feels pain when the auricle is pulled. 2. The patient has dry cerumen in the auditory canal. 3. The patient reports a persistent ringing in the ears. 4. The patient describes a sensation of the room revolving.

4 Rationale: An inflamed labyrinth interferes with the transmission of the neural information to the brain. It creates a staggering gait and a strong, spinning, whirling sensation in the patient. Such an ailment is called vertigo. The patient feels pain when the pinna is pulled in case of otitis externa. Dry cerumen in the auditory canal affects hearing and the patient may have conductive hearing loss. Ringing in the ear is termed tinnitus, a "phantom sound" that occurs with cerumen impaction or middle ear infection.

The nurse is caring for an elderly patient diagnosed with conductive hearing loss due to impacted cerumen. Which nursing intervention would be the most beneficial for the patient? 1. Providing hearing aids to the patient 2. Inserting tympanostomy tubes into the ear 3. Leaving the ear undisturbed for four days 4. Irrigating the ear canal with warm solution

4 Rationale: Conductive hearing loss due to impacted cerumen is common among elderly patients. The best method to treat this condition is to flush out the impacted cerumen by irrigating the ear canal with a warmed solution of mineral oil, hydrogen peroxide, and water. Cerumen impaction blocks the conduction of sound in patients using hearing aids as well, so providing hearing aids will not correct the hearing loss in this situation. Tympanostomy tubes are inserted surgically into the patient's tympanic membrane to help drain ear effusions and reduce the pressure in the ear, but they do not help remove impacted cerumen. Leaving the ear undisturbed for four days may result in excessive buildup and drying of cerumen inside the ear, which may worsen the patient's symptoms.

The nurse observes dappled brown patches inside on a patient's cheek. What does this indicate? 1. A symptom of mumps 2. A sign of oral infection 3. An early sign of measles 4. Adrenal insufficiency

4 Rationale: Dappled brown patches may be seen during the examination of the buccal mucosa. It is an indication of chronic adrenal insufficiency or Addison disease. Stensen duct is the opening of the parotid salivary gland; the orifice of the duct looks red with mumps. An oral infection called thrush or candidiasis is a white, cheesy curd-like patch on the tongue and the buccal mucosa. It rubs off, leaving a clear, raw denuded surface. Koplik spots on the cheek are early warning signs of measles.

The nurse is caring for a patient with epistaxis. Which symptom is most likely to be seen in this patient? 1. Loss of smell 2. Perforated septum 3. Thick, creamy nasal drainage 4. Bleeding from the anterior nasal septum

4 Rationale: Epistaxis is bleeding from the anterior nasal septum. It is rarely severe and can be easily controlled. Causes include nose picking, forceful coughing or sneezing, fracture, and coagulation disorder. Loss of the sense of smell is called anosmia. It is due to an inflammation of the nasal mucosa, blockage of nasal passages, or a destruction of one temporal lobe of the brain. Anosmia can be temporary or permanent. A hole in the septum is usually caused by snorting cocaine or methamphetamine. Chronic infection, trauma from continual picking of crusts, or nasal surgery may also result in perforated septum. Acute sinusitis may result in thick, creamy nasal drainage.

While assessing a patient, the nurse suspects the patient has labyrinthitis. Which question would the nurse ask the patient during the assessment? 1. Do you have any discharge from the ears?" 2. "Do you have any difficulty while traveling by air?" 3. "Have you experienced any ear infections in the past?" 4. "Do you ever feel like the room is spinning around you?"

4 Rationale: Labyrinthitis is associated with the inflammation of the labyrinth and results in labyrinth dysfunction, which may impair body balance and result in vertigo. Therefore, during the assessment, the nurse would ask the patient whether he or she feels as if the room is spinning, which is a sign of vertigo. The nurse would ask about ear discharge if the patient had a middle ear infection, such as acute or chronic otitis media.

The nurse observes a bruise-like, dark red, confluent macule on the hard palate. With which condition is this associated? 1. Burton line 2. Pharyngitis 3. Koplik spots 4. Oral Kaposi sarcoma

4 Rationale: Oral Kaposi sarcoma is the most common early lesion in people with acquired immunodeficiency syndrome (AIDS). It appears like a bruised, dark red, confluent macule on the hard palate. A Burton line is a blue line on the border between gingiva and teeth that occurs with lead poisoning. Pharyngitis is a streptococcal infection that may produce peritonsillar abscess. Koplik spots appear as small blue-white spots with irregular red halo scattered over the mucosa opposite to the molars. They are an early sign of measles.

The nurse is assessing a group of children in a health care setting. Which child does the nurse expect to have hearing impairment? 1. A newborn showing acoustic blink reflex 2. A 3-month-old child who cries when there is silence 3. A 1-year-old child who is able to speak in small sentences 4. A 9-month-old who is more reactive to movement than to sound

4 Rationale: The ability to localize sound and respond to name develops at 6 to 8 months, so when a 9-month-old child responds more to movements than to sound, it indicates that the child has a risk of hearing impairment. The presence of an acoustic blink reflex indicates that the newborn is able to react to the sounds. Due to the acoustic blink reflex and microreflex, the child cries when there is complete silence around him or her. Usually, the child would be able to grasp the words said by the people around him or her, and develop intelligible speech by the age of 2 years. The 1-year-old child is able to speak in short sentences; therefore, the nurse would not interpret that the child has risk of hearing impairment.

Which assessment finding should the nurse refer for further investigation? 1. Epulis 2. Migratory glossitis 3. Koplik spots 4. Leukoplakia

4 Rationale: The chalky white, raised patch of leukoplakia is associated with squamous cell carcinoma and needs to be referred to a specialist. An epulisis is a nontender, fibrous nodule of the gum that is seen emerging between the teeth; it is an overgrowth of vascular granulation tissue. An epulis is not cancerous. Migratory glossitis is a pattern of normal coating interspersed with bright red, shiny, circular bald areas caused by atrophy of the filiform papillae, with raised pearly borders. Pattern resembles a map and changes with time. Not significant, and its cause is not known. Koplik spots are small blue-white spots with an irregular red halo scattered over the buccal mucosa. They are an early sign of measles.

What is the function of the eustachian tube in the middle ear? 1. Promotes lubrication of the ear 2. Helps in maintaining balance 3. Prevents the entry of foreign bodies 4. Equalization of air pressure on both sides of the eardrum

4 Rationale: The eustachian tube is the part of the middle ear that equalizes air pressure on both the sides of the eardrum. The external auditory canal is a part of the external ear and it contains wax glands that secrete wax and lubricate the ear. The inner ear contains the bony labyrinth, which aids in hearing and maintaining body balance. The wax secreted by the external auditory canal acts as a barrier against foreign bodies.

What is the function of the auricle? 1. It helps to amplify sound in the inner ear. 2. It helps to maintain the equilibrium of the body. 3. It helps to protect the inner ear from loud sounds. 4. It helps to funnel sound waves into the external auditory canal.

4 Rationale: The external ear is called the auricle or pinna. It has a characteristic shape that helps to funnel sound waves into the external auditory canal for transmission to the middle ear. The semicircular canals of the inner ear help to maintain equilibrium. Sounds need not be amplified; rather, the middle ear helps to protect the inner ear by reducing the amplitude of the loud sounds.

A patient in the hospital experiences epistaxis. What should the nurse instruct the patient to do to stop the bleeding? 1. "Lie down for 10 minutes with the head tilted back." 2. "Sit up straight and cover the nose with a gauze pad." 3. "Sit up straight and tilt the head back for 10 minutes." 4. "Sit up with the head tilted forward and pinch the nose."

4 Rationale: The nurse should ask the patient to sit up with the head tilted forward. The patient should pinch the nose between the thumb and forefinger for 5 to 15 minutes to stop bleeding. The patient must not lie down with the head tilted back, because it may cause the blood to go into the mouth or throat, which is a potential choking hazard. A gauze pad may help absorb the blood but does little to actually stop the nosebleed.

While conducting the otoscopic examination in a newborn, the nurse tilts the newborn's head slightly toward the opposite side of the shoulder. Then, the nurse pulls the newborn's pinna up and backward and holds it gently but firmly. The nurse then holds the otoscope upside down and proceeds to perform further steps. Which action by the nurse needs correction? 1. Tilting the newborn's head slightly 2. Holding the otoscope upside-down 3. Holding the newborn's ear pinna firmly 4. Pulling the newborn's ear pinna up and back

4 Rationale: The nurse should follow all the steps properly while performing otoscopic examination. The order of steps is to check the ear canal or the eardrum thoroughly without causing any trauma to the ear canal. Pulling the ear pinna helps in straightening the ear canal and checking the eardrum. In adults, the ear canal is S-shaped; to straighten it, the nurse pulls the pinna up and back. Newborns have straight ear canals however, so the nurse should pull the pinna down rather than up and back. Tilting the newborn's head slightly toward the opposite shoulder of the respective ears provides a clear view of the eardrum. Holding the otoscope upside down helps in placing the probe into the ears properly. Holding the pinna firmly helps prevent trauma or injury, which may be caused by the newborn's movements.

The nurse documents observations about the light reflex seen on the tympanic membrane during an otoscopic examination. Which observation signifies that the ears are normal? 1. The light reflection is at the 7 o'clock position in both the ears. 2. The light reflection is distorted in both ears. 3. The light reflection is amber yellow in color. 4. The light reflection is at the 5 o'clock position on the right tympanic membrane, and the 7 o'clock position on the left.

4 Rationale: The nurse should systematically explore the landmarks of the tympanic membrane. The cone-shaped light reflex is prominent in the anteroinferior quadrant of the ear. In the right drum, it is at the 5 o'clock position, and in the left eardrum it is in the 7 o'clock position. This is the reflection of the otoscope light. Normally the reflection should be at the 7 o'clock position only in the left eardrum. Distortions in the cone of light can be a sign of increased inner ear pressure or otitis media. The light reflex of amber yellow color is seen in case of middle ear infection.

What is the total number of permanent teeth in an adult? 1. 16 2. 20 3. 28 5. 32

4 Rationale: The total number of permanent teeth present in an adult is 32. There are 16 teeth present in each arch in an adult individual. Twenty deciduous teeth are found in a child. These are replaced by permanent teeth. Four wisdom teeth erupt, generally after 18 years of age. Before the appearance of the wisdom teeth, an adult has only 28 teeth.

How does the normal tympanic membrane appear during an otoscopic examination? 1. Straight and pink 2. Convex and white 3. Opaque and red 4. Concave and pearl gray

4 Rationale: The tympanic membrane is concave with a pearly gray color. A prominent cone of light is seen in the anteroinferior quadrant, which is the reflection of the otoscope light. This structure is obliquely placed and is not straight. The tympanic membrane is not convex or opaque; it is concave and translucent. The normal tympanic membrane is pearly gray, and is not pink, white, or red in color.

The nurse is teaching the parents of a newborn infant about precautions to prevent middle ear infections. Which statement by the parent indicates a need for further teaching? 1. "I should not give pacifiers to my baby." 2. "I should avoid placing my baby in day care if possible." 3. "I should breastfeed my baby for at least 3 months." 4. "I should place my baby in the supine position while feeding with a bottle.

4 Rationale: When an infant is fed in the supine position, some milk may flow into the ear and may increase the bacterial growth, which increases the risk of ear infection. Therefore, the nurse should advise the parents to avoid bottle-feeding the infant in the supine position and should suggest an inclined position instead while feeding. Pacifier use has also been linked to the risk of infection, so parents should not be encouraged to give pacifiers to their infants. Infants who are placed in daycare have an increased risk of infection because day care providers may not supervise bottle feeding as closely or devote as much attention to infection prevention. Breast milk provides antibodies and improves the immunity of the infant. Giving only breast milk to the infant for the first 3 months provides the best protection against ear infections.

The nurse assesses the hypoglossal nerve or cranial nerve XII by asking the patient to stick out the tongue. Which finding should the nurse associate with a fine tremor of the tongue? 1. Alcoholism 2. Cerebral palsy 3. Damaged nerve 4. Hyperthyroidism

4 Rationale: When the nurse asks the patient to stick out the tongue, it should protrude in the midline. This is a normal finding. A fine tremor of the tongue visible when the patient sticks out the tongue indicates hyperthyroidism. A coarse tremor of the tongue occurs with alcoholism and cerebral palsy. The tongue deviates toward the paralyzed side in a patient with cranial nerve XII damage.

While performing an otoscopic examination in a two-week-old newborn, the nurse finds that the newborn has hypomobile tympanic membrane. What does the nurse suspect from this finding? 1. The newborn has a keloid. 2. The newborn has a furuncle. 3. The newborn has cholesteatoma. 4. The newborn has serous otitis media.

4 Rationale: While retracting the ear drum pressure in the ear canal decreases, which creates a vacuum in the middle ear and decreases the motility of the drum. The retraction of the eardrum and the drum hypomobility occur due to serous otitis media, which is a middle ear infection. A keloid is an overgrowth of the scar tissue that is caused by trauma such as ear piercing. A furuncle is a painful, reddened, and infected hair follicle, which is associated with lymphadenopathy, but not with hypomobile tymphanic membrane. Cholesteatoma is an overgrowth of the epidermal tissue in the middle ear or temporal bone. Keloid, furuncle, and cholesteatoma do not create a high vacuum and do not result in drum hypomobility.