Ch 18 Mouth, Throat, Nose, Sinuses

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1. The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?
A) Thrush
B) Leukoplakia
C) Gingivitis
D) Canker sore
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2. In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client?
A) Decreased sense of taste
B) Difficulty hearing
C) Impaired sense of smell
D) Occasional dizziness
3. 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?
A) History of allergies
B) Incomplete immunization record
C) History of epistaxis (nosebleeds)
D) Prolonged tonsillar enlargement
4. The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?
A) Sit with the head of the bed at 45 degrees during meals.
B) Be aware of the possibility of temporomandibular joint pain.
C) Thoroughly chew small amounts of food with each mouthful.
D) Drink fluids before and after, but not during, meals.
5. When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority?
A) Determining whether the client is receiving phenytoin therapy
B) Referring the client for further evaluation
C) Encouraging the client to enroll in a smoking cessation program
D) Providing the client with information on proper mouth care
6. While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding?
A) Have the client provide a 24-hour diet recall.
B) Review the client's medication regimen.
C) Prepare the client for a thyroid screening.
D) Assess the client's cranial nerve function.
7. A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition?
A) Crepitus over the maxillary sinuses
B) Frontal sinuses nontender to palpation
C) Red, tender tympanic membrane
D) Increased amounts of saliva production
10. When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding?
A) Enlarged pharyngeal tonsils
B) Enlarged palatine tonsils
C) Enlarged adenoids
D) Enlarged lingual tonsils
11. The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask? A) Have you lost any teeth recently? B) How would you describe your typical diet? C) Has your dentist screened you for oral cancer recently? D) Are you able to taste the food you eat?A) Have you lost any teeth recently?12. During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess? A) Asking if the client experiences dry mouth often B) Inspecting for inflammation of the tonsils C) Checking for a deviated nasal septum D) Performing a focused respiratory assessmentC) Checking for a deviated nasal septum13. While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority? A) Anterior-posterior and lateral chest x-ray B) Complete blood count with differential C) Dietitian referral D) Intravenous fluid replacementD) Intravenous fluid replacement14. The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next? A) Facilitate blood testing for human immunodeficiency virus (HIV). B) Refer the client to a primary care provider for medication. C) Asses the client's laboratory values for zinc deficiency. D) Assess the client for signs of jaundice.B) Refer the client to a primary care provider for medication.15. The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group? A) Italian Americans B) Native Americans C) African Americans D) Non-Hispanic AmericansB) Native Americans16. On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment? A) History of abuse B) Chronic nose picking C) Mucosal polyps D) Chronic allergiesD) Chronic allergies17. A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following? A) The physician will write a prescription for antibiotics. B) The drainage will need to be cultured. C) A repeat procedure will be done in 1 week to compare findings. D) The headaches are most likely not from a sinus infection.D) The headaches are most likely not from a sinus infection.18. 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 of the following as components of saliva? Select all that apply. A) Salts B) Proteins C) Fats D) Mucus E) AmylaseA) Salts D) Mucus E) Amylase19. The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal? A) Absence of red glow on transillumination of sinuses B) Nasal mucosa pale pink and swollen C) Tonsils 2+ D) Pinkish, spongy soft palateD) Pinkish, spongy soft palate20. When assessing a client for possible oral cancer, the nurse should most closely inspect which area? A) Buccal mucosa B) Hard palate C) Area under the tongue D) Along the gum lineC) Area under the tongue21. A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer? A) Would you say that you're prone to getting mouth ulcers? B) Do you brush and floss daily? C) Do you use tobacco, whether smoking or chewing? D) How often do you usually go to the dentist in a year?C) Do you use tobacco, whether smoking or chewing?22. The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize? A) How often do you use over-the-counter nasal sprays? B) How often do you take Tylenol? C) How many drinks of alcohol do you have in a typical day? D) Would you say that you eat a balanced diet?A) How often do you use over-the-counter nasal sprays?23. The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his 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. How can the nurse begin to identify the specific allergens that cause the man's symptoms? A) Ask the client if his allergies respond to OTC antihistamines. B) Ask the client about the timing of his allergy symptoms. C) Perform a detailed inspection of the client's ears and throat using an otoscope. D) Perform transillumination of the client's sinuses.B) Ask the client about the timing of his allergy symptoms.24. An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding? A) A 4-year-old girl who has all of her primary teeth B) A 20-year-old man who has type 1 diabetes mellitus C) A 39-year-old woman who has just finished a course of oral antibiotics D) A 77-year-old man who describes himself as being healthyD) A 77-year-old man who describes himself as being healthy25. Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding? A) Swab the lesion to obtain a sample for culture and sensitivity testing. B) Recommend that the client gargle with saltwater twice daily for several days. C) Refer the client to her primary care provider promptly. D) Determine whether the lesion can be removed with a sterile cotton-tipped applicator.C) Refer the client to her primary care provider promptly.26. A client has presented with a terrible head cold, and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply. A) Inspection B) Palpation C) Auscultation D) Percussion E) TransilluminationB) Palpation D) Percussion E) Transillumination27. The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis? A) Resonance on percussion B) Dull sounds C) Tympanic sounds D) Pain on percussionD) Pain on percussion28. The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem? A) Risk for injury related to potential esophageal trauma B) Risk for oral infection related to dysphagia C) Risk for aspiration related to decreased swallowing ability D) Risk for excess fluid volume related to decreased peristalsisC) Risk for aspiration related to decreased swallowing ability29. A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance? A) Thick, white plaques on the tongue surface B) Dry appearance with fissures present C) Diffuse reddened lesions that bleed easily D) Firm, raised nodules that are pink or redA) Thick, white plaques on the tongue surface30. The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say aaah. This finding should prompt the nurse to focus on which of the following during subsequent assessment? A) The client's nutritional status B) The client's neurological status C) The client's immune function D) The client's respiratory functionB) The client's neurological status