PrepU ch.18 assessing mouth, nose, throat, and sinuses

The teeth are composed of what three layers? Select all that apply. -Crown -Neck -Root -Enamel -Pulp

-Crown -Neck -Root Explanation: The three layers of the teeth include the crown, neck and root. The enamel and pulp are layers of the crown. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 358. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 358

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

-False Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 359. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 359

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? -gloves -penlight -tongue depressor -speculum -tuning fork

-gloves -penlight -tongue depressor Explanation: For the assessment of the oral mucosa, the nurse needs to have available gloves to prevent the possible transmission of infection, a penlight to optimize visibility of the oral cavity, and a tongue depressor to prevent the tongue from obstructing view of the posterior oral cavity and throat. A speculum and tuning fork are required when conducting a physical examination of the ear. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 366. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 366

The client has experienced a stroke and has dysphagia. The nurse knows this is what? a.Difficulty swallowing b.Painful swallowing c.Lack of gag reflex d.Difficulty talking

a. Difficulty swallowing Explanation: Difficulty swallowing is dysphagia. Odynophagia is painful swallowing. Difficulty talking is aphasia. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 362. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 362

The nurse assesses the frontal sinus where? a.Above the eyes b.Below the eyes c.Above jaw d.Below jaw

a. Above the eyes Explanation: The frontal sinuses are located above the eyes. The maxillary sinuses are located above the jaw. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 359. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 359

The Kiesselbach plexus is the most common site for what? a.Anterior nosebleeds b.Posterior nosebleeds c.Sinusitis d.Infections

a. Anterior nosebleeds Explanation: The Kiesselbach plexus is the most common site for anterior nosebleeds. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 361. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 361

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.B12 b.C c.D d.K

a. B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 369. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 369

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

a. Cancers often occur. Explanation: It is important to inspect the sides and undersurface of the tongue and the floor of the mouth, because these are areas where cancer most often develops. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, pp. 369-370. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 369-370

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely... a.Candida albicans infection. b.Koplik spots. c.leukoplakia. d.Fordyce spots.

a. Candida albicans infection. Explanation: Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (Candida albicans) infection. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 368. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 368

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

a. Cilia Explanation: Cilia capture and propel debris toward the nasopharynx. Turbinates are bony lobes that project from the lateral walls of the nasal cavity. The lacrimal duct receives drainage. The columella divides the nostrils. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, pp. 358-359. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 358-359

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 from the second upper molars c.Right side of the frenulum at the base of the gums d.Posterior aspect of the tongue bilaterally

a. Either side of the frenulum on the floor of the mouth Explanation: The nurse should inspect the Wharton's ducts on either side of the frenulum on the floor of the mouth. Stenson's ducts, not Wharton's ducts, are visible on the buccal mucosa across from the second upper molars. The right side of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate sites to inspect for salivary ducts. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 370. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 370

A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client? a.Ensure a patent airway b.Begin antibiotics immediately c.Correct client's dehydration d.Obtain a throat culture

a. Ensure a patent airway Explanation: 4+ tonsils obstruct 75%-100% to midline in the back of the throat. Potential or actual acute airway obstruction requires immediate intervention and is priority. Antibiotics are likely prescribed, but airway is priority. The client may be dehydrated, but the tonsil abscess must be drained and airway ensured first. A throat culture may be collected, but the priority concern is ensuring a patent airway. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

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

a. Eye drops and sucking on hard candy may used to relieve dryness. Explanation: Sjogren syndrome is a chronic inflammatory disorder characterized by decreased lacrimal and salivary gland secretion. Eye drops and hard candy can provide relief from dryness. Sjogren syndrome does not affect blood pressure. Sjogren syndrome is not contagious or sexually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

The client is experiencing red gums that are bleeding. The nurse identifies this as what? a.Gingivitis b.Torus palatinus c.Bifid uvula d.Ludwig's angina

a. Gingivitis Explanation: Gingivitis is an inflammation of the gums with bleeding. Torus palatinus is a bony risk running in the middle of the hard palate. Bifid uvula is a minor cleft. Ludwig's angina is a swelling that pushes the tongue up and back. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 361. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 361

The nurse understand the molars are responsible for what? a.Grinding b.Biting c.Cutting d.Support

a. Grinding Explanation: The molars are responsible for grinding and final chewing before swallowing. The incisors are responsible for biting food. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

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.Leukoplakia b.Petechiae c.Gingivitis d.Fordyce granules

a. Leukoplakia Explanation: Leukoplakia is white patches inside of the mouth. Gingivitis is inflamed gums that bleed. Small red spots occur with petechiae. Fordyce granules are while or yellow papules appearing on the cheeks, tongue and lips. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 364. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 364

A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? a.Sitting with the head erect and at the eye level of the nurse b.Tilting the head backwards, with the neck flexed c.Semi-recumbent position, with the chin lifted d.Prone, with arms relaxed at the sides

a. Sitting with the head erect and at the eye level of the nurse Explanation: The nurse should ask the client to assume a sitting position with the head erect and at the eye level of the examiner. Tilting the head backwards and a semi-recumbent position with the chin lifted will make it more difficult to visualize the mouth and nose. The prone position will make transillumination and palpation of the sinuses more difficult for the examiner. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 366. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 366

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.Hopelessness b.Acute Pain c.Ineffective Health Maintenance d.Self-Care Deficit

b. Acute Pain Explanation: The nursing diagnosis of Acute Pain can be confirmed because it meets the major defining characteristic of verbalization of sore throat. Impaired swallowing is not related to impaired neurologic or neuromuscular function. There is no criterion to confirm that this client cannot maintain health maintenance because this is an acute problem. No data exist to confirm the nursing diagnoses of Self-Care Deficit or Hopelessness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for... a.aspiration. b.malocclusion. c.gingivitis. d.throat soreness.

a. aspiration. Explanation: Dysphagia (difficulty swallowing) or odynophagia (painful swallowing) may be seen with poorly fitting dentures. Dysphagia increases the risk for aspiration, and clients with dysphagia may require consultation with a speech therapist. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 362. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 362

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

b. A large amount of exudate in the sinuses Explanation: Frontal or maxillary sinuses are tender to palpation in clients with allergies or acute bacterial rhinosinusitis. If the client has a large amount of exudate, you may feel crepitus upon palpation over the maxillary sinuses. Normal, air-filled sinuses would not demonstrate crepitus. Obstruction of the nostril by a foreign object would prevent sniffing or blowing air through the nostrils, but would not produce crepitus. A perforated septum would also not produce crepitus. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 374. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 374

A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue? a.At the very tip b.Both sides c.Frenulum d.Posteriorly near tonsils

b. Both sides Explanation: The sides of the tongue are the most common area for carcinoma to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity. The nurse should inspect all surfaces of the tongue & buccal mucosa for the presence of oral cancer. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 358. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 358

During a physical examination the nurse observes the condition shown on a client's hard palate (white spots). How should the nurse document this finding? a.Diphtheria b.Candidiasis c.Torus palatinus d.Kaposi sarcoma

b. Candidiasis Explanation: Thrush or candidiasis is a yeast infection on the palate, although it may appear elsewhere in the mouth. It is characterized by thick, white plaques that are somewhat adherent to the underlying mucosa. In diphtheria, the throat is dull red, and a gray exudate is present on the uvula, pharynx, and tongue. A torus palatinus is a midline bony growth in the hard palate that is fairly common in adults. Its size and lobulation vary. The lesions of Kaposi sarcoma are deep purple. The lesions may be raised or flat. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 368. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 368

A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? a.Reddish b.Cyanotic c.Pallor d.Swelling

b. Cyanotic Explanation: Cyanotic lips are seen in cases of cold or hypoxia. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Pallor around the lips is a finding in clients with anemia and shock. Swelling of the lips is common in local or systemic allergic reaction. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 367. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 367

On assessing a client's mouth, the nurse finds that the uvula is deviated and the palate fails to rise. Which of the following conditions should the nurse most suspect in this client? a.Cerebrovascular accident b.Paralysis of cranial nerve X (vagus) c.Native American heritage d.Tonsil infection

b. Paralysis of cranial nerve X (vagus) Explanation: Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A bifid or split uvula is a common finding in the Native American population. A cerebrovascular accident may cause asymmetrical or loss of movement of the uvula. Infection of the tonsils does not cause a deviation of the uvula and failure of the palate to rise. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 371. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 371

A client reports occasionally experiencing hoarseness. In response to this statement, the nurse asks, "What makes the hoarseness go away?" Which characteristic of the client's symptom is the nurse assessing? a.treatment b.relieving factors c.duration d.onset

b. relieving factors Explanation: If the nurse is asks the client what makes the hoarseness go away, this assesses the relieving factors of the symptom. When the nurse is asking the client if the hoarseness been previously treated, this assesses the treatment of the symptom. If the nurse asks the client how long does the hoarseness lasts, this assesses the duration of the symptom. When the nurse asks the client how often the hoarseness is experienced, this assesses the onset of the symptom. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 361. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 361

A client is brought to the emergency department in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process? a.End-stage liver disease b.Small-bowel obstruction c.Diabetic ketoacidosis d.Respiratory infection

c. Diabetic ketoacidosis Explanation: The nurse should suspect the client of having diabetic ketoacidosis on the basis of the fruity smell of his breath. Clients with end-stage liver disease have a sulfur odor in their breath. Clients with small-bowel obstructions have a fecal smell, and clients with respiratory infection have foul odors in their breath. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 371. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 371

A client comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? a.Thompson plexus b.Sinuses c.Kiesselbach plexus d.Wharton ducts

c. Kiesselbach plexus Explanation: The most common site of nasal bleeding is the Kiesselbach plexus on the anterior septum. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 361. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 361

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.Ala nasi, vestibule, and ethmoid sinuses c.Vestibule, nasal passages, and nasopharynx d.Turbinates, ethmoid sinuses, and nasal passages

c. Vestibule, nasal passages, and nasopharynx Explanation: After entering the anterior nares, air enters the vestibule and passes through the narrow nasal passage to the nasopharynx. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 359. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 359

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. 4+ Explanation: The nurse should document the tonsillar grading as 4+ because the tonsils are so large that they are touching one another. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Grade 1 tonsils are ones that are barely visible. Tonsils that touch the uvula are graded 3+. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 379. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 379

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the anterior portion of the tongue? a.Use a square gauze pad to hold the client's tongue to each side. b.Use a penlight and tongue depressor to retract the lips. c.Put on gloves and retract the client's lips and cheeks. d.Ask the client to stick the tongue out between the lips.

d. Ask the client to stick the tongue out between the lips. Explanation: Sticking the tongue out between the lips allows visualization of the anterior portion of the tongue. The correct technique to examine the sides of the tongue is to use a square gauze pad to hold the client's tongue to each side. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. Putting on gloves and retracting the client's lips and cheeks is a technique used to examine the gums and teeth. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 369. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 369

An older adult client who wears dentures reports having soreness of the gums. Which intervention should the nurse recommend to the client to alleviate this problem? a.Avoid excessive intake of sugary foods. b.Use toothpaste containing fluoride. c.Have a dental examination every 2 years. d.Massage the gums daily.

d. Massage the gums daily. Explanation: Regular massage of the gums relieves soreness and pressure from dentures on the underlying soft tissue. Avoiding excessive intake of sugary foods is a strategy to reduce the risk of cariogenic bacteria. The client with dentures will not use toothpaste but rather a cleanser specific for dentures. The client with dentures should have a dental examination every year; however, this intervention will not provide immediate relief from the gum soreness. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018.

A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection? a.Dark pink, moist, & free of discharge b.Pale pink, swollen, with watery exudate c.Bluish gray, swollen, with watery exudate d.Red, swollen, with purulent discharge

d. Red, swollen, with purulent discharge Explanation: The nurse should find red, swollen nasal mucosa with purulent discharge in the client diagnosed with upper respiratory tract infection. Dark pink, moist nasal mucosa which is free of exudate is a normal finding. Pale pink, swollen nasal mucosa with watery exudate and bluish gray, swollen nasal mucosa with watery exudate is found in cases of allergy. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 373. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 373

A 58-year-old man who is HIV-positive has presented with thick, white plaques on his oral mucosa. What diagnosis would the nurse first suspect? a.Diphtheria b.Kaposi's sarcoma c.Torus palatinus d.Thrush

d. Thrush Explanation: Thick, white plaques that are partially adherent to the oral mucosa are associated with thrush. HIV and AIDS are predisposing factors. People with HIV and AIDS are also prone to Kaposi's sarcoma, but these lesions are typically deep purple. Diphtheria causes a dull redness in the throat, and a torus palatinus is a bony growth in the hard palate. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 368. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 368

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.Cool and dry expired air b.Move mucus to the back of the throat c.Moisten and filter expired air d.Warm and humidify inspired air

d. Warm and humidify inspired air Explanation: The vascular and ciliated mucous lining of the nasal cavities warms and humidifies inspired air. It is the function of the cilia alone to move mucous in the nasal cavities and filter the inspired air. Reference: Weber, J.R., & Kelley, J.H., Health Assessment in Nursing, 6th ed., Philadelphia, Wolters Kluwer, 2018, Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses, p. 359. Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses - Page 359