3016 CH 15 (prepU + review Qs)

Which of the following is part of the upper gastrointestinal tract?

A. Nasal septum

B. Sinuses

C. Throat

D. Adenoids

C. Throat

The nurse is assessing the nares to evaluate the site of epistaxis. The most common site of bleeding in which of the following?

A. Osteomeatal complex

B. Nasal septum

C. Kesselbach plexus

D. Woodruff plexus

C. Kesselbach plexus

The nurse knows that the floor of the mouth is highly vascular so it is a good location for which of the following?

A. Absorption of sublingual medications

B. Identification of malignancy in the pharyngeal foss

C. Considering an infection with streptococcus

D. Aspiration even if the gag reflex is present

A. absorption of sublingual medications

Acute airway obstruction is a situation that should be

a. Reassessed during the next visit

b. Evaluated within 8 hrs

c. Further assessed thoroughly

d. Quickly assessed and treated

D. quickly assessed and treated

Risk factors for nose, sinus, mouth, and throat problems include

A. Topical decongestant use, smoking, and allergies

B. Smoking, allergies, and high blood cholesterol

C. Allergies, high blood cholesterol, and topical decongestant use

D. High blood cholesterol, topical decongestant use, and smoking

A. topical decongestant use, smoking, and allergies

The nurse has assessed the nose and documents normal findings as

A. Nose asymmetrical with clear drainage

B. Nose symmetrical and midline

C. Nose asymmetrical and proportional to facial features

D. Nose symmetrical with yellow drainage

B. nose symmetrical and midline

The nurse is assessing a patient who has been taking antibiotics for 10 days. Oral assessment is important because of the increased risk for which of the following?

A. Fordyce granules

B. Pharyngitis

C. Anosmia

D. C. albicans

D. C. albicans

An adolescent male presents with complaints of nosebleeds. The nurse would further assess for

A. Hemangioma

B. Nasal trauma

C. Angiofibroma

D. Cystic fibrosis

B. Nasal trauma

The nurse assesses the child with purulent unilateral nasal discharge. The nurse knows that the most likely causative factor is

A. Allergic rhinitis

B. Choanal atresia

C. Foreign body in nose

D. Cystic fibrosis

C. foreign body in nose

During routine physical examination of a 20 yo woman, the nurse notes a septal perforation. This finding may be significant for which of the following causes?

A. Illicit drug use

B. Nose picking

C. Nasal trauma

D. Bifid uvula

A. illicit drug use

The nurse is assessing the uvula and soft palate of a client with left-sided cranial nerve X paralysis and observes for movement when the client says “aaah.” Which finding(s) should the nurse document as abnormal? Select all that apply.

• Soft palate does not rise.

• Uvula deviates to the right side.

• No redness is present.

• Uvula hangs freely in the midline when client is at rest.

• Soft palate has no exudate present.

a b

The nurse understand the molars are responsible for what?

• Grinding

• Biting

• Cutting

• Support

• Grinding

A client is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate?

• Vitamin B12 deficiency

• Vitamin D deficiency

• Vitamin C deficiency

• Vitamin B1 deficiency

• Vitamin B12 deficiency

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

• mandible.

• frenulum.

• gums.

• soft palate.

• frenulum.

The client asks the nurse about possible strategies to reduce dust mites in the home. Which is the best response by the nurse?

• “Vacuuming the house at least once every week can help.”

• “Removing houseplants can decrease the number of mites.”

• “All pets should be groomed daily and bathed every month.”

• “Close windows during periods of peak flower blooming.”

“Vacuuming the house at least once every week can help.”

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.

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.

A nurse should assist a client to assume what position in order to best assess the mouth, nose, and sinuses?

• Sit with the head erect and at the eye level of the nurse

• Tilt the head backwards with the neck flexed

• Semi-recumbent position with the chin lifted

• Prone with arms relaxed at the sides

• Sit with the head erect and at the eye level of the nurse

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 acetaminophen?”

• “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?”

The client comes to the clinic with reports of a sore throat, difficulty swallowing, malaise, and anorexia. Upon examination, the nurse notes a red throat with enlargement of the tonsils and jaw and neck lymph nodes. Which test does the nurse expect the health care provider to order? Select all that apply.

• Rapid strep test

• CBC with differential

• Monospot test

• CT scan of tonsils

• Biopsy of tonsils

a b c

What lines the cheeks?

• Lingual mucosa

• Alveolar mucosa

• Buccal mucosa

• Labial mucosa

• Buccal mucosa

A nurse is working with a client who has an impaired ability to move the tongue. They explains that they were 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 X (vagus)

• Cranial nerve VII (facial)

• Cranial nerve XII (hypoglossal)

• Cranial nerve XII (hypoglossal)

 Explanation:

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.

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about their history of environmental allergies, the client states, "I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies." What would the nurse do next?

• Ask the client if the allergies respond to OTC antihistamines.

• Ask the client about the timing of allergy symptoms.

• Perform a detailed inspection of the client's ears and throat using an otoscope.

• Perform transillumination of the client's sinuses.

• Ask the client about the timing of allergy symptoms.

 Explanation:

Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round. Transillumination and otoscopic examination will not help identify the cause of the client's allergy symptoms. Similarly, the response of the allergies to antihistamines will not determine the ultimate cause of the symptoms.

A client reports having a dry sore throat for the last few days. What should the nurse consider as causing this client’s symptom? Select all that apply.

• Allergy

• Oral cancer

• Acid reflux

• Viral infection

• Dry heat irritation

a c d e

 Explanation:

Throat irritation can occur with an allergy, because of reflux of stomach acids into the back of the throat, a viral infection such as the flu, or irritation from dry heat. Oral cancer affects the ability to swallow. A sore throat that persists without healing may indicate throat cancer.

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.

a d

 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.

Which clinical manifestation would the nurse expect to find when assessing the client with pharyngitis? Select all that apply.

• exudates

• fever

• dysphagia

• aphasia

• epistaxis

a b c

 Explanation:

When assessing the client with pharyngitis, the nurse would expect the clinical manifestations of fever, dysphagia, and exudates in addition to sore throat, malaise, anorexia, redness of the pharyngeal walls, and rash. Aphasia, the inability to understand or express speech, and epistaxis or nosebleed would not be expected clinical manifestations of pharyngitis.

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.

During an oral assessment, the nurse identifies that client has white patches in their mouth. How would this be documented in the medical record?

• Leukoplakia

• Petechiae

• Gingivitis

• Fordyce granules

• 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.

A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which component(s) of saliva? Select all that apply.

• salts

• starches

• fats

• mucus

• amylase

a d e

 Explanation:

The secretion of the salivary glands is saliva, which is a watery serous fluid containing salts, mucus, and salivary amylase. The enzyme amylase breaks down starches, but neither starches nor fats are a component of saliva.

The nurse identifies this as trapping debris and propelling it toward the nasopharynx.

• Cilia

• Turbinates

• Columella

• Lacrimal duct

Cilia

The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?

• Finish the bottle of nasal spray to clear the infection effectively.

• Nasal spray can be shared between family members only.

• Administer the nasal spray in a prone position.

• Overuse of nasal spray may cause rebound congestion.

Overuse of nasal spray may cause rebound congestion.

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?

• "When was your last dental examination?"

• "Can you tell me what you eat in a day?"

• "How much water do you drink in a day?"

• "Which medications do you take?"

• "Have you noticed any bluish-black swelling under your tongue?"

a b c d

Which glands are responsible for mouth drainage? Select all that apply.

• Sublingual

• Submandibular

• Parotid

• Lacrimal

• Sebaceous

a b c

During the history a client reports a blockage in the upper portion of the nasal passage. Which of the following would the nurse expect as a prominent symptom?

• Decreased sense of taste

• Difficulty hearing

• Inability to smell

• Occasional dizziness

• Inability to smell

A child presents to the health care facility with new onset of a foul-smelling, purulent drainage from the right nare. The parent states that no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

• Reassure the parent 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.

A client is found to have leukoplakia, and the nurse is teaching the client about measures to reduce the client's risk. Which of the following statements would the nurse include in the teaching?

• "Increase your intake of foods high in iron and zinc."

• "Avoid smoking and alcohol use."

• "Make sure to get lots of vitamin D from the sun."

• "Use a humidifier to increase the moisture in the environment."

• "Avoid smoking and alcohol use."

 Explanation:

Leukoplakia is a precursor to oral cancer. The nurse would instruct the client to avoid smoking and alcohol use, because leukoplakia may be seen in clients who smoke heavily and use alcohol. The nurse would also instruct the client to eat a healthy, balanced diet, including fruits and vegetables that are high in vitamin A (vitamin A deficiency is a risk factor for oral cancer). The client also needs to be instructed to avoid excessive exposure to sunlight and ultraviolet light. Using a humidifier would be appropriate to help prevent sinusitis.

The nurse prepares material about oropharyngeal cancer for a community health fair. What should the nurse include as actions to prevent the development of this disease? Select all that apply.

• Avoid smoking

• Limit sun exposure

• Practice daily oral hygiene

• Avoid excessive alcohol use

• Eat fresh fruits and vegetables

a d e

The nurse is teaching an anatomy class to pre-nursing students. Today the nurse is discussing the upper respiratory system. What structures are important links in the chain of lymph nodes guarding the body from invading organisms? (Mark all that apply.)

• Adenoids

• Sinuses

• Paranasal sinuses

• Tonsils

 a d

Explanation:

The adenoids, or pharyngeal tonsils, are located in the roof of the nasopharynx. The tonsils, the adenoids, and other lymphoid tissue encircle the throat. These structures are important links in the chain of lymph nodes guarding the body from invasion by organisms entering the nose and the throat. The sinuses and paranasal sinuses are not lymph tissue.

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.

a d

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.

While conducting a comprehensive assessment on a new client, the client states, “I’ve had these mouth and tongue sores for a few weeks that do not seem to heal.” The nurse assesses the client’s mouth and finds thickened lumpy areas with a rough and crusty appearance. What is the best action of the nurse?

• Document the findings.

• Refer the client for further evaluation of the sores.

• Request medication for aphthous stomatitis (canker sores).

• Recommend the client use over-the-counter mouthwash twice a day.

• Refer the client for further evaluation of the sores.

 Explanation:

Lesions that last for more than 2 weeks are not normal and need to be further examined with possible referrals to a specialist. The nurse will document the findings, but nurse will also need to refer the client. Recommending the use of over-the-counter mouthwash twice a day will not be beneficial and will cause pain due to the alcohol contained in most mouthwashes. The client's symptoms symptoms do not indicate canker sores.

A line across the tip of the nose is seen in an 8-year-old client. The nurse would focus on which area of assessment?

• History of abuse

• Chronic nose picking

• Mucosal polyps

• Chronic allergies

Chronic allergies

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.

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?

• Cool and dry expired air

• Move mucus to the back of the throat

• Moisten and filter expired air

• Warm and humidify inspired air

• 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.

The nurse is 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.

A young client is concerned about a hard mass in the midline of their palate that they have 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.

A nurse examines a client reporting 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+.

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.

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

• 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.

When assessing a client's lips, which of the following is an indication of a viral infection?

• Aphthous ulcer

• Edema

• Cracking

• Swelling

• Aphthous ulcer

 Explanation:

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.

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?

• "When was your last dental examination?"

• "Can you tell me what you eat in a day?"

• "How much water do you drink in a day?"

• "Which medications do you take?"

• "Have you noticed any bluish-black swelling under your tongue?"

a b c d

The Kiesselbach plexus is the most common site for what?

• Anterior nosebleeds

• Posterior nosebleeds

• Sinusitis

• Infections

• Anterior nosebleeds

Which of the following assessment findings of the mouth, nose, and throat of an older adult client would the nurse attribute to the aging process?

• Deviated septum

• Peritonsillar abscess

• Candidiasis

• Tongue fissures

• Tongue fissures

A client diagnosed with Sjogren syndrome should be given which instructions?

• Eye drops and sucking on hard candy may used to relieve dryness.

• Blood pressure should be checked frequently.

• Condom use can reduce the risk of transmission.

• Taking mucus thinning medication can relieve symptoms.

• 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 sxually transmitted. Taking mucus thinning medication does not provide relief but could actually lead to additional dryness.

Which action by the nurse is appropriate to provide a clear view of the uvula for observation?

• Depress the tongue slightly off center

• Ask the client to say "aaah"

• Press firmly on the back of the tongue

• Ask the client to stick out the tongue

• Ask the client to say "aaah"

 Explanation:

Asking the client to say “aaah” and instructing them 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.

Which characteristic of the gums should a nurse expect to assess in a client who has scurvy?

• Pink, moist, firm

• Red, bleeding

• Enlarged, reddened

• A grey-white line

• Red, bleeding

 Explanation:

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.

Upon inspection of a 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. Paralysis of cranial nerve X (vagus) often causes the uvula to deviate to one side and the palate to fail to rise. A CVA may cause asymmetrical or loss of movement of the uvula. Enlargement of the tonsils does not cause a bifid uvula.

The nurse is caring for an adult client in the emergency department with epistaxis. The client asks the nurse about the potential causes of this condition. What should the nurse include in the response? Select all that apply.

• nose picking

• inflammation

• drying and crusting of the nasal mucosa

• foreign bodies

• oral contraceptives

a b c d

A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection. On inspection of the client's tongue, the nurse should anticipate what appearance?

• Thick, white plaques on the tongue surface

• Dry appearance with fissures present

• Diffuse reddened lesions that bleed easily

• Firm, raised nodules that are pink or red

• Thick, white plaques on the tongue surface

 Explanation:

Thrush appears as thick, white plaques on the tongue or the hard palate. The client's tongue would not be dry or have lesions and nodules present.

The nursing instructor is discussing the normal functioning of the nose and sinuses with the nursing class. What would be the best description of the major factors related to the normal functioning of these structures? Select all that apply.

• Patency of the sinus ostia

• Normal cilia function

• Normal quality and quantity of the mucus

• Deep cervical and retropharyngeal nodes

• An abundant lymph supply

a b c

dysphagia; difficulty drinking

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

A client has lost a significant amount of weight due to painful swallowing. The nurse assesses the client for potential underlying causes. Which of the following may be contributing to the client’s painful swallowing? Select all that apply.

• nasal polyps

• tumors of the throat

• neuromuscular disorders

• vestibular imbalances

• gastroesophageal reflux disease (GERD)

b c e

A client presents with rhinorrhea. Which area of assessment would yield the most pertinent information?

• History of allergies

• History of dysphagia

• Frequency of nosebleeds

• Tonsillar enlargement

• History of allergies

 Explanation:

Rhinorrhea (thin, watery, clear nasal drainage) may indicate chronic allergy, which is the primary area for assessment and will yield the most pertinent information. Dysphagia would suggest a problem with the throat. 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.

A nurse practitioner is conducting the physical assessment of a school-age child. The child's parent states that it seems like their child always has strep throat. What is the likely medical outcome for this child?

• Dental caries

• Pharyngitis

• Hypertrophic tonsils

• Chronic tonsillitis

• Chronic tonsillitis

 Explanation:

Recurrent strep infections are likely to result in chronic tonsillitis. Pharyngitis can be triggered by chronic tonsillitis. None of the other options are a result of a strep infection.

In examining a client's mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following?

• Wharton's ducts

• Foster's ducts

• Stenson's ducts

• Burton's ducts

• Stenson's ducts

 Explanation:

Stenson's ducts (parotid ducts) are located on the buccal mucosa across from the second upper molars and, in a healthy mouth, are visible with flow of saliva and with no redness, swelling, pain, or moistness in area. Wharton's ducts are openings from the submandibular salivary glands and are located on either side of the frenulum on the floor of the mouth. Foster's and Burton's are not the names of actual ducts.

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, the nurse 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.

The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about their history of environmental allergies, the client states, “I'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies.” What would the nurse do next?

• Ask the client if their allergies respond to OTC antihistamines.

• Ask the client about the timing of their allergy symptoms.

• Perform a detailed inspection of the client's ears and throat using an otoscope.

• Perform transillumination of the client's sinuses.

• Ask the client about the timing of their allergy symptoms.

 Explanation:

Pollens cause seasonal rhinitis, whereas dust and other environmental allergens may cause rhinitis year round. Transillumination and otoscopic examination will not help identify the cause of the client's allergy symptoms. Similarly, the response of the allergies to antihistamines will not determine the ultimate cause of the symptoms.

A child presents to the health care facility with new onset of a foul smelling, purulent drainage from the right nare. The parent states no other signs of an upper respiratory tract infection are present. What is an appropriate action by the nurse?

• Reassure the parent 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, so 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.

The nurse is inspecting a client's Wharton ducts. The nurse would expect to find these at which location?

• Either side of frenulum on floor of the mouth

• Ventral surface of the tongue

• Buccal mucosa across from the second upper molars

• At the back of the mouth midline of the soft palate

• Either side of frenulum on floor of the mouth

 Explanation:

Wharton's ducts are located on either side of the frenulum on the floor of the mouth. The ventral surface of the tongue is the underside portion of the tongue. Stenson's ducts are located on the buccal mucosa across from the second upper molars. The uvula is located at the back of the mouth, midline of the soft palate.

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)

A nurse is providing care to a dark-skinned client of Mediterranean descent. On assessment the nurse observes that the client’s lips are bluish and freckled. What is the best action of the nurse?

• Document the findings as normal.

• Notify the health care provider.

• Ask the client if they are cold.

• Check for signs of blood loss.

• Document the findings as normal.

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

A client arrives reporting nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache, and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for in this client?

• Chewing betel nuts

• Exposure to the sun

• Asthma

• Heavy alcohol use

• Asthma

 Explanation:

This client shows symptoms of sinusitis. Risk factors for sinusitis include a nasal passage abnormality, aspirin sensitivity, cystic fibrosis, chronic obstructive pulmonary disease (COPD), an immune system disorder, hay fever, asthma, and regular exposure to pollutants such as cigarette smoke. The other answers listed—chewing betel nuts, exposure to the sun, and heavy alcohol use—are all risk factors for oropharyngeal cancer, but not for sinusitis.

Which finding, if noted when inspecting a client's mouth, would require immediate follow-up?

• Thrush

• Leukoplakia

• Koplik spots

• Canker sore

• Leukoplakia

 Explanation:

Leukoplakia is a precancerous lesion that requires immediate follow-up. Although thrush, which indicates a candidal infection; Koplik spots, which are an early sign of measles; and canker sores, which are associated with adrenocortical insufficiency, are abnormal findings, the evidence of leukoplakia is serious and needs immediate evaluation.

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

a b c e

A nurse is performing a comprehensive assessment on a 40-year-old client. The client states, “I have noticed that I have a decreased sense of smell lately. What would cause that?” What is the best response by the nurse? Select all that apply.

• “Lesions of cranial nerve I (the olfactory nerve) or cranial nerve VII (the facial nerve) could be the cause.”

• “Neurologic disorders such as Alzheimer disease or Parkinson disease could be the cause.”

• “Decreased sense of smell is a normal part of aging.”

• “Did you recently suffer any head injuries?”

• “Do you have a history of nasal polyps?”

a b d e

During examination 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 duct 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 sides of the frenulum at the base of the gums and on the posterior aspect of the tongue bilaterally are not appropriate to inspect salivary ducts.

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.

a d

An older adult client comes to the clinic for an annual exam. As the nurse is assessing the client’s nose, which of the following would the nurse consider normal age-related changes? Select all that apply.

• nasal polyps

• chronic rhinitis

• change in sense of smell

• decreased sensitivity of taste buds

• difficulty breathing through the nose

c d

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.

The nurse is performing a physical assessment of a client who reports of a sore throat and stuffy nose. The nurse notes a red inflamed throat and slight fever and suspects strep. Which of the following tests would be ordered to confirm this diagnosis?

• Bronchoalveolar lavage

• Pulmonary function test

• Throat culture

• Sputum specimen

Throat culture

The nurse is assessing the client’s hypoglossal nerve (CN XII). Which nursing action would the nurse perform?

• The nurse gently places a tongue blade on the posterior tongue.

• The nurse instructs the client to smile and show upper and lower teeth.

• The nurse instructs the client to say “ah” and notes a rise of the uvula.

• The nurse instructs the client to identify common scents on a sniff card.

• The nurse gently places a tongue blade on the posterior tongue.

 Explanation:

The nurse gently places a tongue blade on the posterior dorsum to assess the function of the hypoglossal nerve (CN XII). The nurse would ask the client to identify common scents to assess the olfactory nerve (CN I). The nurse assesses the facial nerve (CN VII) by instructing the client to smile and then show teeth. The nurse instructs the older adult to say “ah” to assess the function of the vagus nerve (CN X).