Chapter 15: Nose, Sinuses, Mouth, and Throat Assessment

A student nurse is taking a nursing test and is asked a question about the columella. What is the best description of the term columella?

A. The structure that divides the nares

An oncology nurse is caring for a client newly diagnosed with an occult nasopharyngeal malignancy. Where would the nurse expect this malignancy to be?

B. Rosenmuller's fossa

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

C. Kiesselbach's plexus

A nursing instructor is discussing areas of health promotion related to the nose, sinuses, mouth, and throat. What topics would the instructor be most likely to cite? (Select all that apply.)

A. Tobacco use

C. Obstructive sleep apnea

E. Oral health

When doing a risk assessment of the nose, sinuses, mouth, and throat, what finding might indicate an allergy?

C. Frequent childhood infections

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?

D. White coated tongue

The nurse is caring for an older adult client with a nasogastric feeding tube ordered by the physician. The nurse notes that the client is not a mouth breather and having no difficulty breathing. While inserting the feeding tube, the nurse encounters difficulty getting the tube through the nares. What should the nurse suspect?

A. Deviated septum

A client presents at the urgent care clinic with severe pain and pressure around the eyes. The nurse practitioner suspects a sinus infection. What is considered the typical standard diagnostic technique in evaluating sinus disease?

B. computed tomography (CT) scanning

The nurse is caring for an adult client who presents at the clinic with reports of general malaise and fatigue. Physical assessment reveals that the client's lips are dry and cracked. What might this indicate?

C. Inadequate hydration

A nurse caring for a client admitted 2 days ago following a cerebral vascular accident. The nurse notes that the client is frequently coughing, has food falling from the mouth while eating, and frequently chokes. What would be the most pertinent nursing diagnosis for this client?

D. Impaired swallowing

What is the purpose of the tongue? (Select all that apply.)

B. Manipulates solids and liquids when eating and drinking

C. Helps with the identification of sweet, sour, salty, and bitter tastes

D. Assists in speech production

The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.)

C. VII

D. IX

E. XII

A nurse is conducting an admission assessment on an older adult client with an intractable oral infection. The client tells the nurse that he cannot smell things as well as he once could. What should the nurse do initially?

A. Recognize that the sense of smell decreases with age

A nurse is preparing an educational event for the parents of children with respiratory disorders. What would the nurse tell the parents about allergies?

C. Allergy can affect any target organ in the body

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

Which information in the client's history is a priority safety concern?

C. Recent immigrant complains of cough

The nurse is at a school health fair and is teaching a group of teenagers about preventing periodontitis. Which statement made by a teen indicates understanding of the teaching?

A. "Vaping can lead to periodontitis."

The nurse is assessing a client who appears to have a swollen thyroid gland (goiter). Which of the following is a priority question the nurse should ask the client?

A. "Do you have any difficulty swallowing?"

The nurse is caring for a client admitted to the medical surgical unit with neck tenderness, drooling, and dysphagia. In reviewing the orders from the health care provider (see above), which order should the nurse question?

A. regular diet as tolerated

The nurse is caring for a client in a medical-surgical unit. In reviewing the assessment notes (see above), the nurse considers which findings to be indicative of the need for a focused oral assessment?

A. weight change