Chapter 15 Nose, Sinuses, Mouth, and Throat
crepitus
A grating or grinding sensation caused by fractured bone ends or joints rubbing together; also air bubbles under the skin that produce a crackling sound or crinkly feeling.
In which client would the nurse identify receding gums (tuột nướu) as an expected assessment finding? A 4-year-old girl who has all of her primary teeth A 20-year-old man who has type 1 diabetes mellitus A 39-year-old woman who has just finished a course of oral antibiotics A 77-year-old man who describes himself as being healthy
A 77-year-old man who describes himself as being healthy Explanation: Receding gums are abnormal in younger clients; in older clients, the teeth may appear longer because of age-related gingival recession, which is common. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379-394
During a physical examination the nurse observes the condition shown on a client's hard palate. How should the nurse document this finding? Diphtheria Candidiasis Torus palatinus Kaposi sarcoma
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 406
When assessing a client's lips, which of the following is an indication of a viral infection? Aphthous ulcer Edema Cracking Swelling
Dryness or cracking of the lips may indicate inadequate hydration. Lesions or aphthous ulcers may represent a viral infection. Swelling or edema of lips suggests allergy. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea? History of allergies Incomplete immunization record History of epistaxis (nosebleeds) Prolonged tonsillar enlargement
History of allergies Explanation: Rhinorrhea-running nose (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Immunizations are unlikely to relate directly to this sign. Nosebleeds may be seen with overuse of nasal sprays, excessively dry mucosa, hypertension, leukemia, and other blood disorders. Tonsillar enlargement may be associated with tonsillitis or other infectious processes. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 385. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 385
buccal mucosa
Mucous membrane lining the cheek.
A client has been brought to the emergency unit of a health care facility following an automobile accident. Which finding about the lips supports the diagnosis of anemia and shock? Reddish Cyanotic Pallor Swelling
Pallor Explanation: Pallor around the lips is a finding in clients with anemia and shock. The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Cyanotic lips are seen in cases of cold or hypoxia. Swelling of the lips is common in local or systemic allergic reaction.
A client is experiencing sinus tenderness associated with a head cold. What techniques should the nurse use to assess this client's symptom? (Select all that apply.) Press up on the frontal sinuses from under the bony brows. Press down on the head. Press up on the area next to the ear. Press up on the maxillary sinuses. Press down on the lower jaw.
Press up on the frontal sinuses from under the bony brows. Press up on the maxillary sinuses. Explanation: Only the frontal and maxillary sinuses are readily accessible to physical examination. To assess for sinus tenderness, the nurse should press up on the frontal sinuses from under the bony brows and press up on the maxillary sinuses. Pressing down on the head, pressing on the area next to the ear, and pressing down on the lower jaw are not techniques to assess the frontal and maxillary sinuses. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389-394
Which glands are responsible for mouth drainage? Select all that apply. Sublingual Submandibular Parotid Lacrimal Sebaceous
Sublingual Submandibular Parotid Explanation: The sublingual, parotid and submandibular glands are responsible for mouth drainage. Sebaceous glands may be located on tongue. The lacrimal duct is part of the nose. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 377
The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include? Sit with the head of the bed at 45 degrees during meals. Be aware of the possibility of temporomandibular joint pain. Thoroughly chew small amounts of food with each mouthful. Drink fluids before and after, but not during, meals.
Thoroughly chew small amounts of food with each mouthful. Explanation: Dysphagia, difficulty swallowing, increases the risk of aspiration. Thoroughly chewing small bites of food decreases this risk and is most critical for safety. Fully raising the head of the bed prevents aspiration. Dysphagia is not associated with temporomandibular joint pain, and the client may drink during meals unless explicitly contraindicated. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: Ala nasi, turbinates, and nasopharynx Ala nasi, vestibule, and ethmoid sinuses Vestibule, nasal passages, and nasopharynx Turbinates, ethmoid sinuses, and nasal passages
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 374
The nurse is assessing an individual with facial injury following a motor vehicle accident. Which finding would suggest a fracture of the nose? crepitus mucus polyps turbinates
crepitus Explanation: The presence of crepitus, a crackling or grating sound, is suggestive of a fractured nose. Polyps are grape-like swollen nasal membranes. Mucus is suggestive of infection. The turbinates are normal structures of the internal nose. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389
Stenson's ducts
landmark: opening of the parotid salivary gland (salivary gland on cheek over buccal mucosa putting secretions in the mouth) -- use tongue blade to hold cheek out; note slight protrusion opposite second upper molar is The parotid duct, or Stensen duct, is the major duct of the parotid gland, which is the major salivary gland. This duct serves as a conduit for saliva between the substance of the parotid gland and the oral cavity
frontal sinuses
located in the frontal bone just above the eyebrows
adenoids
mass of lymphatic tissue in the nasopharynx
The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the ethmoidal sinuses. laryngeal sinuses. maxillary sinuses. sphenoidal sinuses.
maxillary sinuses. Explanation: The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 393
Soft palate (of mouth)
posterior portion, not supported by bone
The roof of the oral cavity of the mouth is formed by the anterior hard palate and the teeth. gums. muscles. soft palate.
soft palate. Explanation: The roof of the oral cavity is formed by the anterior hard palate and the posterior soft palate. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 376
A nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding? "How many cigarettes do you smoke daily?" "Do you drink a lot of coffee or tea?" "Are you experiencing any tooth pain?" "Do you have trouble chewing your food?"
"Are you experiencing any tooth pain?" Explanation: Brown spots on the chewing surface on the teeth may indicate tooth decay which also may cause pain with chewing. Clients who smoke or drink large quantities of coffee or tea may have a brownish tint to the teeth. Trouble chewing would indicate missing or malocclusion of the teeth. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379-382
The nurse is assessing a client with chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? "How often do you use over-the-counter nasal sprays?" "How often do you take Tylenol?" "How many drinks of alcohol do you have in a typical day?" "Would you say that you eat a balanced diet?"
"How often do you use over-the-counter nasal sprays?" Explanation: Overuse of nasal sprays may cause nasal irritation, nosebleeds, and rebound swelling. These symptoms are not characteristic of poor nutrition or heavy alcohol use. Acetaminophen does not result in bleeding or chronic nasal congestion. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 383-400. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 383-400
A client's spouse reports to the nurse that the client sometimes stops breathing during sleep and asks if this is serious. What is the best response by the nurse? "Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." "Everyone experiences periods of apnea when they are in deep REM sleep." "Your spouse is suffering from a normal condition of aging known as sleep apnea." "Your spouse has sleep apnea, which can cause problems with blood pressure."
"Sleep apnea is a risk factor for obesity, hypertension, heart attack, and stroke." Explanation: Individuals with sleep apnea are at risk for hypertension, heart attack, brain attack (stroke), and motor vehicle accidents. While the response where the nurse states sleep apnea causes problems with blood pressure is correct, it is not specific in what the problem is: hypertension. As we age, the risk for sleep apnea increases, but sleep apnea is not a normal part of aging and the response does not answer the spouse's question. Sleep apnea is not an expected finding of REM sleep. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 385
The prenatal client asks the nurse why her gums are swollen. What is the best response by the nurse? "You have gingival hyperplasia as a result of changes in your hormones with your pregnancy." "You have candidiasis as a result of changes in your hormones with your pregnancy." "You have leukoplakia as a result of changes in your hormones with your pregnancy." "You have herpes simplex virus as a result of changes in your hormones with your pregnancy."
"You have gingival hyperplasia as a result of changes in your hormones with your pregnancy." Explanation: The prenatal client has developed gingival hyperplasia caused by fluctuations in hormones associated with pregnancy. Leukoplakia is a white oral lesion that is firmly attached to the mucosa. Candidiasis can occur in newborns, immunosuppressed individuals, and following antibiotic or corticosteroid therapy and is a white sticky mucus on the tongue or oral mucosa. Herpes simplex virus is transmitted by direct contact with an infected person and is characterized as a painful oral lesion that evolves into pustules that rupture, weep, and crust, usually at a lip-skin juncture. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 408
A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? 1+ 2+ 3+ 4+
1+ Explanation: The nurse should document the tonsillar grading as 1+ because the tonsils are just visible. Grade 2 tonsils are midway between the tonsillar pillars and the uvula. Tonsils that touch the uvula are graded 3+, and tonsils that are so enlarged that they touch each other are graded 4+. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 392
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? 1+ 2+ 3+ 4+
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: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 392. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 392
A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? Pink, moist, firm Red, bleeding Enlarged, reddened A grey-white line
A grey-white line Explanation: A grey-white line along the gum line is seen in cases of lead poisoning. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia.
A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? Normal, air-filled sinuses A large amount of exudate in the sinuses Obstruction of the nostril by a foreign object A perforated septum
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 388-389
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? Hopelessness Acute Pain Ineffective Health Maintenance Self-Care Deficit
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.
When assessing a client, the nurse notes a brownish ridge along the gum line. This finding would be considered normal in a client from what background? African American Native American Pacific Islander Asian American
African American Explanation: In dark-skinned clients, the gums are more deeply colored; a brownish ridge is often found along the gum line. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
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? B12 C D K
B12 Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B12 or niacin. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
A nurse is working with a client who has an impaired ability to smell. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? Cranial nerve I (olfactory) Cranial nerve V (trigeminal) Cranial nerve VII (facial) Cranial nerve IX (glossopharyngeal)
Cranial nerve I (olfactory) Explanation: Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. Cranial nerves V (trigeminal), VII (facial), IX (glossopharyngeal), and XII (hypoglossal) assist with some functions related to ingestion, taste, preparing food for digestion, and speech. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 375
A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. What assessment findings should the nurse anticipate along with this condition?
Crepitus over the maxillary sinuses Explanation: With a sinus infection with large amounts of exudates, the nurse would most likely palpate crepitus over the maxillary sinuses. The frontal or maxillary sinuses would be tender. The tympanic membrane would be red and tender with acute otitis media. Increased amounts of saliva are unrelated to the findings of a sinus infection. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389
The nurse notes that a client's gums are swollen and overgrown. What should the nurse include when assessing this client? Alcohol intake Smoking history Nutritional intake Current medications
Current medications Explanation: Enlarged reddened gums that may cover some of the exposed teeth may occur with the use of medications such as phenytoin. Chalky white raised patches on the buccal mucosa are associated with alcohol intake and smoking. Bleeding gums may be caused by a vitamin deficiency. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 408
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? Either side of the frenulum on the floor of the mouth Buccal mucosa across from the second upper molars Right side of the frenulum at the base of the gums Posterior aspect of the tongue bilaterally
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 377-389
A mother of a client complains of getting no sleep because of excessive snoring from the client every night. The nurse is reviewing with the mother what causes the snoring. Based on this information, what is the best response to the mother of the client about the cause of snoring? Enlargement of the adenoids Elevation of the soft plate Elevation of the uvula Swollen Eustachian tubes
Enlargement of the adenoids Explanation: Enlargement of the adenoids can cause snoring or obstruction of the upper airway. During the act of swallowing, the soft palate and uvula elevate to block the nasal cavity, preventing food from entering the respiratory system. The auditory (Eustachian) tubes connect the nasopharynx with the middle ear. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 385
During the health history of the nose and sinuses, a client complains of having rhinorrhea. What question would the nurse ask to determine associated manifestations of this symptom? In which side does it occur? How long does it last? What color is the drainage? Are there any other symptoms?
Explanation: Asking if there are any other symptoms assesses the manifestations associated with rhinorrhea. Asking the client about which side it occurs assesses the location. Asking how long it lasts assesses the duration. Asking the client about the color of drainage assesses the characteristics of the symptom. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 389. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389
A client is upset because the right medial incisor tooth is broken at the gum line. Which tooth on the diagram is the client referring to? Click to select the correct part of the image.
Explanation: The medial incisor is also referred to as being the "front" tooth. The client's right front tooth is broken at the gum line. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 378
The nurse is planning instructions for a client with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.) How to breathe through the mouth Importance to increase oral fluids Safety measures because of a loss of smell Expect a sore throat and difficulty swallowing Remind that the voice may sound different
How to breathe through the mouth Importance to increase oral fluids Safety measures because of a loss of smell Remind that the voice may sound different Explanation: Because the nose is the site of inspiration and expiration, the nurse will need to instruct the client on mouth breathing. Because the nose filters, warms, and adds moisture to the air, the nurse will need to instruct the client to increase oral fluids. Because the nose is the sensory organ for smell, the nurse will need to instruct the client on safety measures because the nose is broken. Because the nose provides resonance to speech, the nurse will need to remind the client that the voice may sound different because of the broken nose. The functions of the nose do not include throat soreness or effect swallowing. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 374
A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The mother states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse? Reassure the mother that this is common in children Inspect the nostrils with an otoscope Assess for allergies to antibiotic Have the child blow the nose to assess drainage
Inspect the nostrils with an otoscope Explanation: Because the drainage is unilateral, the most likely cause is a foreign body obstruction. The nurse should inspect the nostrils for patency and the presence of a foreign body. It is not a normal finding in children to have unilateral foul-smelling drainage from the nose. This child will not need an antibiotic, thus the nurse does not need to assess for allergies to medication. Blowing the nose may or may not dislodge the object and may cause further trauma to the nare. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 400-402
After describing how to assess the sinuses to a group of students, the students demonstrate understanding of the teaching when they identify which sinuses as being located in the upper jaw? Frontal Maxillary Ethmoidal Sphenoidal
Maxillary Explanation: The maxillary sinuses are located in the upper jaw. The frontal sinuses are located above the eyes. The ethmoidal and sphenoidal sinuses are located deeper in the skull and not accessible for examination. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 378
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Encrusted mucous membranes Hardened secretions Erosion of the trachea Noisy breathing
Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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? Cerebrovascular accident Paralysis of cranial nerve X (vagus) Native American heritage Tonsil infection
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 390
The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which finding would the nurse interpret as being normal? Absence of red glow on transillumination of sinuses Nasal mucosa pale pink and swollen Tonsils 2+ Pinkish, spongy soft palate
Pinkish, spongy soft palate Explanation: The soft palate is expected to be pinkish, soft, spongy, and movable. A negative red glow on transillumination of the sinuses indicates that a sinus is filled with pus or fluid. Nasal mucosa that is pale pink and swollen suggests allergies. Tonsils greater than 1+ are considered abnormal. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, pp. 389-391. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 389-391
Which assessment of the tongue should a nurse recognize as abnormal? Ventral surface with visible veins Fissured, topographical pattern Red with loss of papillae Pale pink and moist
Red with loss of papillae Explanation: A smooth, red, shiny tongue without papillae is indicative of a loss of vitamin B 12 or niacin. The normal tongue has visible veins on the ventral surface and is pink or pale in color and moist. A normal variation seen in the older client is a fissured, topographical map-like tongue. Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 394. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 394
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? Dark pink, moist, & free of discharge Pale pink, swollen, with watery exudate Bluish gray, swollen, with watery exudate Red, swollen, with purulent discharge
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. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 401
A client who is semiconscious is brought to the emergency department of a health care facility after being rescued from a fire. Which finding of the lips supports the diagnosis of carbon monoxide poisoning? Reddish Cyanotic Pallor Swelling
Reddish The finding of reddish lips supports the diagnosis of carbon monoxide poisoning. Cyanotic (brushing) lips are seen in cases of cold or hypoxia. 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: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process? End-stage liver disease Small bowel obstruction Diabetic ketoacidosis Respiratory infection
Small bowel obstruction Explanation: Clients with small bowel obstructions have a fecal smell to their breath. The nurse should suspect the client of having diabetic ketoacidosis if there is a fruity smell on the breath. Clients with end-stage liver disease have a sulfur odor in their breath. Clients with respiratory infection have foul odors in their breath.
The nurse is assessing the client's vagus nerve (CN X). Which nursing action would the nurse perform? The nurse instructs the older adult to say "ah." The nurse asks the client to identify common scents. The nurse palpates the maxillary sinus areas. The nurse inspects the buccal mucosa and tongue.
The nurse instructs the older adult to say "ah." Explanation: The nurse instructs the older adult to say "ah" to assess the function of the vagus nerve (CN X). Palpation of the maxillary sinus areas should not elicit tenderness or fullness, which are suggestive of infection (sinusitis). The nurse would inspect the buccal mucosa and tongue to identify poor oral hygiene, infection, and trauma. The nurse would ask the client to identify common scents to assess for a loss of smell. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 390
Upon inspection of a Native American client's oral cavity, a nurse observes a bifid uvula. What should the nurse recognize about this finding? The client should be assessed for a cerebrovascular accident (CVA). Paralysis of cranial nerve X (vagus) nerve is likely to be present. This is often a normal finding in the Native American population. Enlargement of the tonsils with infection is a common cause.
This is often a normal finding in the Native American population. Explanation: A bifid or split uvula is a common finding in the Native American population. Clients with a bifid uvula may have a submucous cleft palate. A CVA (cerebrovascular accident) may cause asymmetrical or loss of movement of the uvula. Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. Enlargement of the tonsils does not cause a bifid uvula. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
A young man is concerned about a hard mass in the midline of his palate that he has just noticed. Examination reveals that it is indeed hard and in the midline. No mucosal abnormalities are associated with this lesion. The client has no other symptoms. What is the most likely diagnosis? Leukoplakia Torus palatinus Thrush (candidiasis) Kaposi's sarcoma
Torus palatinus Explanation: Torus palatinus is relatively common and benign but can go unnoticed by clients for many years. The appearance of a bony mass can be concerning. Leukoplakia is a white lesion on the mucosal surfaces corresponding to chronic mechanical or chemical irritation. It can be premalignant. Thrush is usually painful and seen in immunosuppressed clients or those taking inhaled steroids for COPD or asthma. Kaposi's sarcoma is usually seen in HIV-positive people; these lesions are classically deep purple. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 379
During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue? Use a square gauze pad to hold the client's tongue to each side Use a penlight and tongue depressor to retract the lips Put on gloves and retract the client's lips and cheeks Ask the client to stick the tongue out between the lips
Use a square gauze pad to hold the client's tongue to each side Explanation: 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. Sticking the tongue out between the lips only allows visualization of the anterior portion of the tongue.
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve? III VI VIII XII
XII Explanation: Decreased tongue strength may occur with a defect of the twelfth cranial nerve. The third cranial nerve is involved with eye muscle movement. The sixth cranial nerve is involved with lateral eye movement. The eighth cranial nerve is involved with hearing and equilibrium Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat.
The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the area on top of the tongue. area underneath the tongue. inside of the cheeks. area near the salivary glands.
area underneath the tongue. Explanation: The area underneath the tongue is the most common site of oral cancer. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 399
Before examining the mouth of an adult client, the nurse should first ask the client to leave dentures in place. don sterile gloves for the procedure. offer the client mouthwash. don clean gloves for the procedure.
don clean gloves for the procedure. Explanation: Before touching any mucous membranes the nurse should apply gloves. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 388
An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are touching the uvula. visible upon inspection. touching each other. midway between the tonsillar pillars and uvula.
touching each other. Explanation: ➢ +1 = extends toarches ➢ +2 = extendsbeyond arches ➢ +3 = extends closeto uvula ➢ +4 = meet midline Reference: Jensen, S, Nursing Health Assessment, 3rd ed., Philadelphia, Wolters Kluwer, 2019, Chapter 15: Nose, Sinuses, Mouth, and Throat, p. 392. Chapter 15: Nose, Sinuses, Mouth, and Throat - Page 392