Nursing Quiz 2

An emergency department nurse is caring for a young child with intractable nose bleeds. What is the most common site of epistaxis? Kiesselbach plexus When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: Cancers often occur 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? Warm and humidify inspired air The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion? Overuse of nasal spray may cause rebound congestion 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? Connects the nasopharynx to the middle ear A nurse is assessing a child who got lost on a camping trip in November and was exposed all night to the elements. Which finding about the lips would support a diagnosis of hypoxia in this client? Cyanotic A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin? B12 A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A large amount of exudate in the sinuses 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? Inspect the nostrils with an otoscope A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client? Heavy use of alcohol, frequent pipe smoking A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client? Rinse mouth with antifungal medication as prescribed A client diagnosed with Sjogren syndrome should be given which instructions? Eye drops and sucking on hard candy may used to relieve dryness The nurse identifies this as trapping debris and propelling it toward the nasopharynx. Cilia The rich blood supply of the nose serves to Warm the inspired air An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explain to the client that grinding the teeth may be a sign of Stress and anxiety A patient comes to the clinic and reports nosebleeds. What area of the nose is the bleeding most likely coming from? Kiesselbach plexus 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? Acute bacterial sinusitis In order to effectively assess the oral mucosa, the nurse should have which assessment tools available? Gloves, penlight, tongue depressor The nurse is performing the assessment shown. What is the nurse assessing in this client? Sinuses During a physical examination the nurse observes the condition shown on a client’s hard palate. How should the nurse document this finding? Candidiasis 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? Kiesselbach’s plexus The autonomic nervous system innervates the salivary glands along with which cranial nerves? (Select all that apply.) VII, IX, XII The frontal sinuses are the only ones readily accessible to clinical examination. False 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? Thrush Which action by the nurse is appropriate to provide a clear view of the uvula for observation? Ask the client to say “aaah” On examination of a client, the nurse detects a tor to the breath. The nurse recognizes this finding as characteristic of what disease process? Small bowel obstruction During an examination of the oral cavity, which technique by the nurse is appropriate to examine the anterior portion of the tongue? Ask the client to stick the tongue out between the lips A nurse examines a client with complaints of a sore throat and finds that the tonsils are just visible. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils? 1+ 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? 4+ A nurse is assessing a small child who has lead poisoning. Which characteristic of the gums should the nurse expect this client? A grey-white line During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts? Either side of the frenulum on the floor of the mouth A client presents to the health care clinic complaining of a sore throat. In examining the client's mouth and throat, the nurse notices that the tonsils on both sides of the oropharynx at the end of the soft palate are swollen. Which tonsils are these? Palatine 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 Frenulum The submandibular glands open under the tongue through openings called Wharton ducts The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the Maxillary sinuses An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client’s tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are Touching each other A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation? How to reduce periodontal disease The nurse is planning to provide discharge teaching for a client with surgical repair of a septal perforation. Which points should be included to address the expected alterations in nasal function? Select all that apply. Techniques for breathing effectively through the mouth, increasing oral fluid intake, awareness of loss of smell, anticipating short term hoarseness of the voice 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? Hypothyroidism The health care provider documented that a client is experiencing edema of the left maxillary sinus. Where on the diagram provided should the nurse expect to observe this swelling? -On the ride side of the screen under the eye Which action by a nurse is appropriate to prevent the gag reflex during observation of the uvula? Depress the tongue slightly off center A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Sitting with head erect and at the eye level of the nurse A client arrives complaining of 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? Asthma A client diagnosed with a peritonsillar abscess exhibits 4+ tonsils and is not able to eat or drink. What is the nurse's priority concern for this client? Ensure a patient airway The nurse assesses the frontal sinus where? Above the eyes The roof of the oral cavity of the mouth is formed by the anterior hard palate and the Soft palate Before examining the mouth of an adult client, the nurse should first Don clean gloves for the procedure A patient is found to have a smooth, glossy tongue. What vitamin deficiency might this indicate? Vitamin B12 deficiency A parent reports her preschool-aged child has been having epistaxis every 2 to 3 days for the past month. Which questions should the nurse ask to determine the possible causes? Select all that apply. Does your child have painless bruising, does your child pick his nose, is you child taking any medications The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client? Vitamin deficiency 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? Deviated septum A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes the client to be febrile with temperature 101.5° F, tonsils are 2+ and red, transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? Acute pain When visualizing the structures of the nose, the nurse recalls that air travels from the anterior nares to the trachea through the: Vestibule, nasal passages, and nasopharynx When inspecting the mouth, the nurse focuses on lateral and vertical surfaces of the tongue and its base, because these are regions where: Cancers often occur You are caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight losses for unidentifiable reasons. The patient a 25-year history of smoking. You perform an assessment and ask the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer? Hoarseness 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? Connects the nasopharynx to the middle ear 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? Pallor A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A large amount of exudate in the sinuses 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? Cranial nerve XII 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? “Are you experiencing any tooth pain” A client presents to the health care clinic with reports of a 3-day history of fever, sore throat, and trouble swallowing. The nurse notes that the client is febrile, with a temperature of 101.5°F, tonsils are 2+ and red, and transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data? Acute pain A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults? Receding and ischemic gums A client who is taking antibiotics for a sinus infection presents with a white coating on the tongue and complains of a burning sensation on the tongue. Which instructions are most appropriate for this client? Rinse mouth with antifungal medication as prescribed A hospitalized client continues to exhibit residual effects of a stroke. Which symptom is the priority concern? Dysphagia During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record? Leukoplakia The nurse is planning instructions for a patient with a broken nose. What teaching will be included to address the alterations in nasal function? (Select all that apply.) Safety measures because of a loss of smell, how to breathe through the mouth, remind that the voice may sound different, importance to increase oral fluids When inspecting a client’s teeth, the nurse notes gingival hyperplasia. What should the nurse assess to determine the cause for this finding? Medications 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? Vagal nerve function The nurse is preparing to examine a patient's mouth floor. To move the tongue to one side for this examination, the nurse will use a: Gauze pad 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? Torus palatinus 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? Warm and humidify inspired air 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? Warm the inspired air 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? Small bowel obstruction What is the common channel for the respiratory and digestive systems? Oropharynx The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the Maxillary sinuses 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? Diets low in fruits and vegetables are a possible risk factor for oral cancer 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? Tongue fissures 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? Massage the gums daily 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? Acute bacterial sinusitis During an assessment the nurse observes the condition shown in the client’s mouth. What should the nurse suspect is occurring with this client? Gingival hyperplasia During a physical examination the nurse observes the condition shown on a client’s hard palate. How should the nurse document this finding? Candidiasis 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? “Are you experiencing sinus pressure and congestion?” 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? Both sides The nurse examines the pharynx of a patient and records that the tonsils are touching the uvula. The nurse would grade the tonsils as 3+ 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? Thrush During an examination of the oral cavity, which technique by the nurse is appropriate to examine the sides of the tongue? Use a square gauze pad to hold the client’s tongue to each side A nurse is working with a client who has an impaired ability to smell. He explains that he was in an automobile accident many years ago and suffered nerve damage that resulted in this condition. Which nerve should the nurse suspect was damaged in this client? Cranial nerve I (olfactory) Which food is most appropriate for the nurse to recommend for a client who suffers frequent nosebleeds due to hereditary hemorrhagic telangiectasia? Cooked vegetables An adolescent wrestler has been diagnosed with herpes simplex virus with weeping lesions on the face, nose, and lips. The client asks the nurse when he can resume competition wrestling. What is the nurse's best response? “You can wrestle after the lesions stop weeping and have crusted over.” The Kiesselbach plexus is the most common site for what? Anterior nosebleeds The nurse assesses the frontal sinus where? Above the eyes 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 Frenulum A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should Refer the client for further evaluation 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 Candida albicans infection An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client’s tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are Touching each other A staff educator from the hospital is providing an event for the hospital staff. The educator is talking about health promotion activities for people with diseases of the nose, mouth, throat, and sinuses. What would the educator include in the presentation? How to reduce periodontal disease The nurse notes that the client's tongue appears as shown. What should the nurse suspect is occurring with this client? Vitamin deficiency What is the purpose of the tongue? (Select all that apply.) Manipulates solid and liquids when eating and drinking, helps with the identification of sweet, sour, salty, and bitter tastes, assists in speech production An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result? Instruct the client to remove upper dentures During an examination of the oral cavity, which technique by the nurse is appropriate to examine the tongue? Use a square gauze pad to hold the client’s tongue to each side 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? Pallor A nurse finds crepitus when palpating over a client's maxillary sinuses. Which of the following should the nurse most suspect in this client? A large amount of exudate in the sinuses A nurse should assist a client to assume what position to best assess the mouth, nose, and sinuses? Sitting with the head erect and at the eye level of the nurse 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? Chewing betel nuts A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects that the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client? Frequent pope smoking, heavy use of alcohol The nurse identifies this as trapping debris and propelling it toward the nasopharynx. Cilia The client is experiencing red gums that are bleeding. The nurse identifies this as what? Gingivitis Which statement regarding oral cancer is correct? Select all that apply. Smoking is a risk factor for oral cancer, risk factors for oral cancer includes oral sex, smoking is a risk factor for oral cancer The nurse is teaching at a community clinic. She explains to the clients that what increases the risk for head and neck cancer? Select all that apply. Tobacco products, alcohol During an oral assessment, the nurse identifies that client has white patches in his mouth. How would this be documented in the medical record? Leukoplakia When assessing a patient the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils? Tonsils are T3 What lines the cheeks? Buccal mucosa The rich blood supply of the nose serves to Warm the inspired air An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should Refer the client for further evaluation During an assessment the nurse observes the client's throat as shown. Which cranial nerve should the nurse suspect is damaged in this client? X