Question 1

The nurse is examining a toddler client. The toddler has a fever and the nurse notes the ear canal is red and swollen and the presence of purulent drainage. Based on this assessment data, which diagnosis does the nurse anticipate?

Accepted Answer

The symptoms described, including a red and swollen ear canal and the presence of purulent drainage, are indicative of otitis externa, an infection of the outer ear canal. Otitis media involves the middle ear, hemotympanum involves the presence of blood in the middle ear, and tophi are deposits of uric acid crystals, typically associated with gout, not ear infections.

Question 2

The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data?

Accepted Answer

A blackish, furry-looking coating on the tongue can be a sign of a fungal infection, often occurring after the use of antibiotics which can disrupt the normal flora of the mouth.

Question 3

The educator is reviewing the Rinne test with a new nurse. Which statement by the nurse indicates an understanding of the test?

Accepted Answer

The Rinne test uses a tuning fork to compare air conduction (AC) and bone conduction (BC) of sound in an individual's hearing process, not an otoscope, whispering, or comparing hearing between ears.

Question 4

The nurse observes white patches on the tympanic membrane. Which question should the nurse ask the client that is most relevant to the finding?

Accepted Answer

White patches on the tympanic membrane can be indicative of scarring from previous ear infections, so asking about a history of ear infections is most relevant.

Question 5

The nurse is preparing to review the secondary sources of data for a client that has experienced a hearing loss. Which diagnostic testing should the nurse anticipate may have been performed? Select all that apply.

Accepted Answer

The answer of The nurse is preparing to review the...

Question 6

An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client?

Accepted Answer

Presbycusis is the most common type of sensorineural hearing loss caused by the natural aging of the auditory system. It typically occurs gradually and affects both ears equally, making it a likely diagnosis for an older adult experiencing hearing loss.

Question 7

The nurse educator is teaching a group of students about cultural differences to consider when conducting an ear, nose, and throat assessment. Which statement by a nursing student indicates appropriate understanding of the information presented?

Accepted Answer

The correct statement is B, which reflects an understanding of genetic variations in earwax consistency among different ethnic groups. Asians and Native Americans are more likely to have dry, flaky earwax due to a specific genetic variation. The other options (A, C, D) are not supported by evidence as being specifically related to Asians or making broad generalizations that do not accurately reflect cultural or genetic differences in health conditions.

Question 8

The nurse conducting the Rinne test notes that the client hears the bone conduction sound longer than the air conduction sound. Which should the nurse anticipate documenting?

Accepted Answer

The answer of The nurse conducting the Rinne test notes...

Question 9

The nurse notes there is no red glow when transilluminating the maxillary sinuses. Which initial question should the nurse ask the client?

Accepted Answer

The answer of The nurse notes there is no red...

Question 10

The nurse observes that the Wharton's ducts are painful, reddened, and swollen. Which additional assessment finding should the nurse anticipate?

Accepted Answer

The symptoms described suggest inflammation or infection of the salivary glands, which can lead to reduced saliva production and result in a dry mouth.

Question 11

The nurse is assessing the client's nasal mucosa and notes the presence of a thin, watery discharge. The client complains of sneezing and nasal congestion. Based on this data, which does the nurse suspect?

Accepted Answer

The symptoms of a thin, watery discharge, sneezing, and nasal congestion are indicative of rhinitis, which is inflammation of the nasal mucosa often caused by allergies or infections.

Question 12

The nurse is assessing several children in a pediatric clinic. Which child is experiencing a delay in the eruption of decidual teeth?

Accepted Answer

The 18-month-old child with only 6 deciduous teeth is experiencing a delay in tooth eruption. Typically, children have about 8 teeth by their first birthday and should have most of their deciduous teeth by 18 months.

Question 13

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data?

Accepted Answer

Pallor and cyanosis of the oral cavity and lips indicate a lack of oxygen (hypoxia) in the blood, making the administration of oxygen the priority action to improve the client's oxygen saturation levels.

Quiz 15: Ears, Nose, Mouth, and Throat