Chapter 18: Assessing Mouth, Throat, Nose, and Sinuses

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? a. Cranial nerve I (olfactory) b. Cranial nerve V (trigeminal) c. Cranial nerve VII (facial) d. Cranial nerve IX (glossopharyngeal)

a. Cranial nerve I (olfactory) 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.

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan? a. Diets low in fruits and vegetables are a possible risk factor for oral cancer. b. About 40% of all cancers occur in the lips, mouth, and tongue. c. The incidence of oral cancers is higher in women than in men. d. Most oral cancers are detected in people in their 70s.

a. Diets low in fruits and vegetables are a possible risk factor for oral cancer. Poor nutrition increases one's risk for oral cancers.

An older adult client reports lacking the desire to eat. The client also reports having discomfort from dentures and a persistently dry mouth. Which questions should the nurse include when taking the health history for this client? a. "When was your last dental examination?" b. "Can you tell me what you eat in a day?" c. "How much water do you drink in a day?" d. "Which medications do you take?" e. "Have you noticed any bluish-black swelling under your tongue?"

a. "When was your last dental examination?" b. "Can you tell me what you eat in a day?" c. "How much water do you drink in a day?" d. "Which medications do you take?" It is important, especially for older adults who wear dentures, to have a dental examination at least once per year to prevent oral damage from an ill-fitting apparatus. Diet and hydration can play a major role in the production of saliva and its flow in the mouth. Identifying nutrition and hydration problems can assist the nurse in planning care and client education. A large variety of medications cause dry mouth. This problem would be exacerbated if the client was taking multiple medications with dry mouth as a side effect. Asking about the medications can help the nurse determine the cause of the dryness. Asking about bluish-black swelling under the tongue assesses for varicose veins in the mouth. These are unrelated to dry mouth and ill-fitting dentures. Varicose veins of the tongue are not clinically significant and would not prevent the client from being able to eat.

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

a. Anterior nosebleeds The Kiesselbach plexus is the most common site for anterior nosebleeds.

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. 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.

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. Whitish, curd-like patches that scrape off over reddened mucosa and bleed easily indicate "thrush" (Candida albicans) infection.

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

a. Cilia 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.

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 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.

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 Gingivitis is an inflammation of the gums with bleeding. Torus palatinus is a bony ridge 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.

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition? a. Herpes simplex b. Angioedema c. Actinic cheilitis d. Syphilis

a. Herpes simplex

You are caring for a client in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The client a 25-year history of smoking. You perform an assessment and ask the client about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? a. Hoarseness b. Dyspnea c. Dysphagia d. Alopecia

a. Hoarseness Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? a. Kiesselbach plexus b. Rosenmuller fossa c. Columella d. Ala

a. Kiesselbach plexus Kiesselbach plexus is the most common site of epistaxis. Rosenmuller fossa is the most common site of nasopharyngeal cancer. The midline columella divides the oval nares (nostrils), which are openings that lead into the internal nose and are lined with the skin and the ciliated mucosa. The anterior slope of the nose is the dorsum, which ends inferiorly at the tip and laterally at the ala.

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? a. Laryngeal cancer b. Laryngeal polyps c. Chronic pharyngitis d. Chronic tonsillitis

a. Laryngeal cancer Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.

What is the common channel for the respiratory and digestive systems? a. Oropharynx b. Nares c. Sinuses d. Frenulum

a. Oropharynx The oropharynx is the common channel for the respiratory and digestive systems. The frenulum is part of the tongue. The nares are part of the nose.

A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? a. Receding and ischemic gums b. Bifid uvula c. Brown spots on the chewing surface of teeth d. Enlarged palatine tonsils

a. Receding and ischemic gums The gums recede, become ischemic, and undergo fibrotic changes as a person ages. A bifid uvula is a common finding in Native Americans, not among older adults. Brown spots on the chewing surface of teeth is an indication of tooth decay and is not associated with aging per se, nor are enlarged palatine tonsils, which are an indicator of tonsillitis.

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 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.

Which glands are responsible for mouth drainage? Select all that apply. a. Sublingual b. Submandibular c. Parotid d. Lacrimal e. Sebaceous

a. Sublingual b. Submandibular c. Parotid 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.

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides 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

a. Use a square gauze pad to hold the client's tongue to each side 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.

Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia? a. Vegetable omelet b. Garlic chicken c. Chocolate pudding d. Salad with ginger dressing

a. Vegetable omelet Dietary recommendations for this bleeding disorder include decreasing foods high in salicylates, such as red wine, spices, chocolate, coffee, and some fruits. Provide education about supplements with antiplatelet activity, such as garlic, ginger, ginseng, gingko, and vitamin E. A vegetable omelet would be the most appropriate food choice since it doesn't contain salicylates or antiplatelet supplements.

A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate? a. Vitamin B12 deficiency b. Vitamin D deficiency c. Vitamin C deficiency d. Vitamin B1 deficiency

a. Vitamin B12 deficiency The tongue and buccal mucosa may appear smoother and shiny from papillary atrophy and thinning of the buccal mucosa. This condition is called smooth glossy tongue and may result from deficiencies of riboflavin, folic acid, and vitamin B 12.

You are teaching a physiology class for pre-nursing students. A student asks what the purpose of the upper airway is in regard to the lower airway. What would be your best answer? a. Warm the inspired air b. Clean the inspired air c. Clean the expired air d. Warm the expired air

a. Warm the inspired air The upper tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange.

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

a. acute bacterial sinusitis Acute bacterial sinusitis should be suspect if there is a recent history of upper respiratory tract infection. The sensitivity for the symptom correlation of upper respiratory tract infections is 90%, and the specificity is 80%. Headache and tenderness on palpation of the sinuses are also features acute bacterial sinusitis. Allergic rhinitis is not associated with an infectious process. Nasal congestion that results from triggering allergens, usually environmental, is the cause. Rhinitis medicamentosa results from excessive use of decongestants used to treat a nonbacterial nasal congestion. Epistaxis is a condition that occurs when the mucosa of the nares is eroded and exposed vessels break leading to what is commonly called a nosebleed. Tenderness and headache are not associated features of epistaxis.

In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? a. gloves b. penlight c. tongue depressor d. speculum e. tuning fork

a. gloves b. penlight c. tongue depressor 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.

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely? a. hypothyroidism b. gingivitis c. dysphagia d. aphthous ulcers

a. hypothyroidism Hoarseness lasting longer than two weeks accompanied by the additional reported symptoms of fatigue and weight gain suggest hypothyroidism. Gingivitis is an inflammation of the gums that often results in bleeding. Dysphagia is a medical term used to describe difficulty swallowing. This can be due to a neuromuscular or oropharyngeal deficit. Hoarseness can accompany dysphagia; however, weight gain and fatigue do not. Aphthous ulcers are a common condition that are restricted to the oral cavity. Commonly called "canker sores," they may be associated with autoimmune problems that create a predisposition to developing oral ulcers.

The nurse asks a client to say "ah" while depressing the tongue with a wooden tongue blade. What is the nurse assessing when performing this technique? a. vagal nerve function b. extent of leukoplakia c. hypoglossal nerve function d. presence of an aphthous ulcer

a. vagal nerve function When asking for a client to say "ah" the nurse assesses for the rise of the soft palate and the uvula which is a test of CN X (the vagal nerve) function. Leukoplakia, a white coating, is visible on the tongue and buccal mucosa and would not need to be assessed by asking the client to say "ah." Evaluating the tongue for symmetry assesses CN XII (hypoglossal nerve) function. An aphthous ulcer would be present on the tongue, lips or buccal mucosa and would not need to be assessed by asking the client to say "ah."

Upon assessment of the tonsils, the nurse finds them to be obstructing 30% of midline. This nurse would document this as what? a. 1+ b. 2+ c. 3+ d. 4+

b. 2+ When tonsils obstruct 25-50% of midline, it would be documented as 2+. A 1+ is an obstruction of up to 25% of midline. A 3+ is an obstruction of 50-75% of midline. If the tonsils obstruct 75-100% of midline, it is a 4+.

Which action by the nurse is appropriate to provide a clear view of the uvula for observation? a. Depress the tongue slightly off center b. Ask the client to say "aaah" c. Press firmly on the back of the tongue d. Ask the client to stick out the tongue

b. Ask the client to say "aaah" Asking the client to say "aaah" and instructing him or her to open the mouth wide makes the uvula more clear for observation. The nurse should depress the client's tongue slightly off center to prevent the gag reflex during observation of the uvula. Depressing the back of the tongue would elicit the gag reflex. Having the client stick out the tongue would not provide a clear view of the uvula.

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 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.

A client reports a 2-pack-per-day history of cigarette smoking. To assess this client for cancer, which part of the tongue is it most important that the nurse inspect? a. At the very tip b. Both sides c. Frenulum d. Posteriorly near tonsils

b. Both sides The sides of the tongue are the most common area for tongue cancer to occur. Tobacco use is the most common risk factor for the development of cancer of the oral cavity.

A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture-related risk factor should the nurse most suspect in this client? a. Infection with human papillomavirus b. Chewing betel nuts c. Heavy alcohol use d. Smoking cigarettes

b. Chewing betel nuts Infection with a certain type of human papillomavirus (HPV), heavy alcohol use, and smoking cigarettes are all risk factors for oropharyngeal cancer, but none of them is specifically associated with Asian culture. Chewing betel nuts, a nut containing a mild stimulant that is popular in Asia, is also a risk factor, associated specifically with this client's culture.

A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? a. Weak gait b. Dysphagia c. Right ptosis d. Facial weakness

b. Dysphagia Dysphagia can lead to aspiration and is the priority concern to maintain a patent airway. A weak gait can lead to falls but is not priority over airway. Right ptosis, or eyelid drooping, and facial weakness can inhibit certain facial movements but this is not a priority concern over airway.

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

b. False

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

b. Inspect the nostrils with an otoscope 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.

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) 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.

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy? a. Pink, moist, firm b. Red, bleeding c. Enlarged, reddened d. A grey-white line

b. Red, bleeding Red, swollen, bleeding gums are seen in gingivitis, scurvy, and leukemia. The nurse may find enlarged, reddened gums as an adverse effect of phenytoin treatment. Pink, moist, firm gums are normal findings of the gums. A grey-white line along the gum line is seen in cases of lead poisoning.

On examination of a client, the nurse detects a fecal odor to the breath. The nurse recognizes this finding as characteristic of what disease process? a. End-stage liver disease b. Small bowel obstruction c. Diabetic ketoacidosis d. Respiratory infection

b. Small bowel obstruction 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.

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? a. Leukoplakia b. Torus palatinus c. Thrush (candidiasis) d. Kaposi's sarcoma

b. Torus palatinus 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.

During an examination of the oral cavity, which technique by the nurse is most likely to improve visualization of the buccal mucosa? 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.

b. Use a penlight and tongue depressor to retract the lips. Using a penlight and tongue depressor to retract the lips helps in visualization of buccal mucosa. 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. 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.

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 a. area on top of the tongue. b. area underneath the tongue. c. inside of the cheeks. d. area near the salivary glands.

b. area underneath the tongue. The area underneath the tongue is the most common site of oral cancer.

The tongue is attached to the hyoid bone and styloid process of the temporal bone and is connected to the floor of the mouth by the a. mandible. b. frenulum. c. gums. d. soft palate.

b. frenulum. The tongue is a mass of muscle, attached to the hyoid bone and styloid process of the temporal bone. It is connected to the floor of the mouth by a fold of tissue called the frenulum.

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? a. "How many cigarettes do you smoke daily?" b. "Do you drink a lot of coffee or tea?" c. "Are you experiencing any tooth pain?" d. "Do you have trouble chewing your food?"

c. "Are you experiencing any tooth pain?" 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.

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 The most common site of nasal bleeding is the Kiesselbach plexus on the anterior septum.

A client has returned from outpatient surgery where a biopsy revealed a nodule on the laryngopharynx. The client asks where this is located. What is the best response by the nurse to the client about the location of laryngopharynx? a. Section of the pharynx from the nares to the uvula b. Part of the pharynx extending from the uvula to the epiglottis c. Lowest portion of the pharynx d. Connects the nasopharynx to the middle ear

c. Lowest portion of the pharynx The laryngopharynx is the lowest portion of the pharynx. It extends from the epiglottis to the openings of the larynx and esophagus. The section of the pharynx that extends from the nares to the uvula is called the nasopharynx. The oropharynx is the part of the pharynx extending from the uvula to the epiglottis. The auditory (Eustachian) tubes connect the nasopharynx with the middle ear.

A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client? a. Frontal b. Ethmoidal c. Maxillary d. Sphenoidal

c. Maxillary 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, which are located in the upper jaw. The ethmoidal and sphenoidal sinuses are smaller, located deeper in the skull, and are not accessible for examination.

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? a. Reddish b. Cyanotic c. Pallor d. Swelling

c. Pallor 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.

Which technique should the nurse use to examine the sinuses of a client with a sinus infection? a. Insert a penlight into the oral cavity & angle it toward the roof of the mouth b. Inspect the frontal and maxillary sinuses with an otoscope c. Press up on the brow on each side of the nose to palpate the frontal sinus. d. Indirectly percuss over the cheekbones for dullness or pain

c. Press up on the brow on each side of the nose to palpate the frontal sinus. Objects should not be placed in the client's mouth unless necessary. Illumination of the frontal sinuses can be accomplished by placing the penlight on the brow of each side of the nose. The nurse should press up on the brow on each side of the nose to palpate the frontal sinus. Frontal and maxillary sinuses cannot be examined through an otoscope. Sinus cavities are not indirectly percussed but may be tapped lightly to detect pain.

Which assessment of the tongue should a nurse recognize as abnormal? a. Ventral surface with visible veins b. Fissured, topographical pattern c. Red with loss of papillae d. Pale pink and moist

c. Red with loss of papillae 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.

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 After entering the anterior nares, air enters the vestibule and passes through the narrow nasal passage to 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 a. ethmoidal sinuses. b. laryngeal sinuses. c. maxillary sinuses. d. sphenoidal sinuses.

c. maxillary sinuses. The frontal sinuses (above the eyes) and the maxillary sinuses (in the upper jaw) are accessible to examination by the nurse.

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client? a. "Do you have a family history of severe headaches?" b. "Are you taking high blood pressure medication?" c. "Have you ever had an injury to your head or neck?" d. "Are you experiencing sinus pressure and congestion?'

d. "Are you experiencing sinus pressure and congestion?'' The client has a recent onset of a frontal headache and the nurse should collect information on additional findings of a sinus infection. Family history of headaches will not provide information about the current headache. High blood pressure causes a headache in the occipital area. A previous injury will not explain the recent acute onset of headache that the client is now experiencing.

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+ 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+.

A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? a. Pink, moist, firm b. Red, bleeding c. Enlarged, reddened d. A grey-white line

d. A grey-white line 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 is working with a client who has an impaired ability to move the tongue. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? a. Cranial nerve I (olfactory) b. Cranial nerve X (vagus) c. Cranial nerve VII (facial) d. Cranial nerve XII (hypoglossal)

d. Cranial nerve XII (hypoglossal) Decreased tongue strength may occur with a defect of the twelfth cranial nerve—hypoglossal—or with a shortened frenulum that limits motion. Receptors of cranial nerve I (olfactory) are located in the nose. These receptors are related to the sense of smell. A loss of taste discrimination occurs with a defect of cranial nerve VII (facial). The palate fails to rise and the uvula deviates to the side with cranial nerve X (vagus) paralysis.

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. 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.

An older client who wears dentures complains of having sore gums. What can the nurse instruct the client to help with 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 every day.

d. Massage the gums every day. 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.

Which instructions should the nurse provide to the client taking a sublingual medication? a. Place the medication along the roof of the mouth. b. The medication is placed inside the cheek. c. Let the medication dissolve on your tongue. d. Put the medication underneath your tongue.

d. Put the medication underneath your tongue. The highly vascular floor of the mouth is a good location for absorption of sublingual medications. The client should be taught to place the medication under the tongue for best absorption.

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 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.

You are doing client teaching with a young mother who has brought her 3-month-old to the clinic for a well-baby check. You know that it is cold season. What information should you provide to the mother to best prevent transmission of organisms? a. Take prescribed antibiotics. b. Use warm salt-water gargles. c. Dress warmly. d. Wash the hands frequently.

d. Wash the hands frequently. Hand washing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly does not suppress transmission. Antibiotics are not prescribed for a cold. Warm, salt-water gargles do not prevent the transmission of organisms, nor does dressing warmly.

A mother brings her 6-month-old child to the clinic for a follow-up assessment after antibiotic treatment for recurring otitis media. What would the nurse expect to find while assessing the client's mouth to best confirm a complication of the treatment? a. Swollen uvula b. Red and white patches in the throat c. White patches firmly attached to the buccal mucosa d. White coated tongue

d. White coated tongue A white coating of the tongue may be oral candidiasis. This condition is very common in clients taking antibiotics. Red and white patches in the throat might indicate strep throat, which would be an unexpected finding. The uvula may be swollen with allergic reactions. White patches attached to the buccal mucosa suggest leukoplakia.

Before examining the mouth of an adult client, the nurse should first a. ask the client to leave dentures in place. b. don sterile gloves for the procedure. c. offer the client mouthwash. d. don clean gloves for the procedure.

d. don clean gloves for the procedure. Before touching any mucous membranes the nurse should apply gloves.