Deck 14: Ears, Nose, Mouth Throat

Question 1

The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane.The nurse should perform which of the following steps to better visualize this structure?
1)Pull the pinna up and back,then reinsert the otoscope
2)Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced.
3)Reinsert the otoscope quickly and press against both sides of the inner auditory canal.
4)Pull the pinna down and back,then reinsert the otoscope.

Answer 1

1

Question 2

The emergency room triage nurse is assessing a child who has a history of a cough and nasal congestion for the last three days.When assessing patency of the nares,the nurse notes that the child is unable to breathe through the right nostril.The nurse would interpret these assessment findings as which of the following?
1)Produced by severe nasal inflammation or obstruction
2)Normal for a child
3)A result of chronic allergies
4)A result of sinusitis

Answer 2

1

Question 3

The client has developed anosmia.The healthcare provider educates the client about the possible causes.The nurse recognizes that which of the following would be an unexpected explanation for this condition?
1)Commonly associated with gingivitis
2)Possibly linked to heredity
3)Related to a diet deficient in zinc
4)An indicator of a neurological problem

Answer 3

1

Question 4

The nurse is educating a group of teenagers in high school about the risks of chewing tobacco.The nurse would include information about which of the following signs of oral cancer?
1)Bleeding and inflamed gums
2)Smooth and shiny tongue
3)Red,swollen tonsils
4)Ulcerations on the lip or under the tongue

Question 5

The nurse is assessing the tympanic membrane of a client and notes the presence of a bluish color.The nurse would suspect which of the following?
1)Acute otitis media
2)Recent head trauma
3)Blocked eustachian tubes
4)History of frequent middle ear infections

Question 6

The client was given several medications during a recent hospital admission.The client has come to the medical office with complaints of tinnitus and bilateral hearing loss.The nurse understands that which of the following medications are associated with hearing loss or tinnitus?
1)Streptomycin
2)Steroid inhalers
3)Aspirin
4)Neomycin
5)Acetaminophen

Question 7

A client presents in the healthcare provider's office with complaints of headache and malaise.The nurse assesses the client and finds that the client has severe pain when the sinuses are palpated.The nurse would suspect which of the following disorders?
1)Sinusitis
2)Mastoiditis
3)Chronic allergies
4)Anemia

Question 8

Which of the following structures attaches the tongue to the floor of the mouth?
1)Hard palate
2)Papillae
3)Frenulum
4)Alveoli sockets

Question 9

A client arrives in the emergency room with complaints of intermittent nosebleeds for the past two days.Which of the following assessments would be a priority for the nurse is this situation?
1)Request information from the client regarding increased propensity for bruising or bleeding.
2)Assess the tonsils for redness or swelling.
3)Obtain a blood pressure.
4)Check for deviated septum.
5)Request information from the client to determine if there was any recent thin,watery drainage from the nose.

Question 10

The client has been brought via ambulance to the emergency room following a motor vehicle accident.The nurse notes that the client's ear is draining clear fluid.What is the nurse's priority nursing action?
1)Request information from the client regarding any chronic allergies.
2)Test the drainage for glucose.
3)Ask the patient if she has experienced a recent middle ear infection.
4)Irrigate the ear with warm mineral oil,peroxide,and flush with warm water.

Question 11

The nurse educates the client about the major functions of the nose and sinuses.Which of the following structures is specifically responsible for filtering,moistening,and warming air that enters the lower portion of the respiratory tract?
1)Olfactory cells
2)Columella
3)Turbinates
4)Nares

Question 12

A client is having difficulty maintaining equilibrium.The client is unable to ambulate without pushing a wheelchair or using a walker.Draw an arrow indicating which part of the ear is not functioning adequately.

Question 13

The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator.The nurse should educate the client about which of the following complications that can occur as a result of this practice?
1)The client has a higher risk of developing otitis externa.
2)The client has a higher risk of developing tophi along the outer rim of the ears.
3)The client could perforate the tympanic membrane.
4)The client could require tympanostomy tubes.
5)The client's cerumen might become impacted.

Question 14

The nurse is examining a 14-month-old child when the mother tells the nurse that the child cries frequently,has a fever,and is pulling at both ears.The nurse suspects the child has which of the following disorders from this assessment data?
1)Otitis media
2)Otitis externa
3)Hemotympanum
4)Tophi

Question 15

During the focused interview,the client admits to regularly abusing cocaine.Which of the following findings does the nurse expect to discover during the physical assessment of the client's nose?
1)The nurse notes that the nasal septum has perforated.
2)Temporomandibular joint pain when the client opens and closes the mouth
3)The septum is noted to be very pale in color.
4)Yeast infection of nasal mucosa and in mouth
5)Difficulty swallowing water

Question 16

The nurse is performing a focused interview with the client.The nurse asks the client if the client has noticed any drainage from the ears,and the client states,"Yes." Which of the following statements indicate that the client may have developed acute otitis media?
1)"The ear canal itself is really red,raw,and sore."
2)"I noticed that the drainage looked clear,like water."
3)"The drainage looks like what is draining from my nose,kind of clear and mucousy."
4)"It is kind of yellowish-reddish color."

Question 17

The client is experiencing the effects of a recent cerebrovascular accident.The client is unable to hear out of the left ear.Which of the following cranial nerves was most likely affected?
1)Cranial nerve I
2)Cranial nerve XII
3)Cranial nerve VIII
4)Cranial nerve VII

Question 18

The nurse is caring for a client who was admitted to the medical unit.The healthcare provider states that the client's Romberg test was positive.As the nurse plans to meet the client's elimination needs,the nurse would implement which of the following interventions?
1)Allow the client to walk independently.
2)Obtain an order for a catheter.
3)Limit fluid intake.
4)Obtain a bedside commode.

Question 19

A client with a fever is also complaining of difficulty hearing.The nurse realizes this client might be experiencing which of the following disorders?
1)Sinusitis
2)Otitis media
3)Tonsillitis
4)Otitis externa

Question 20

The nurse is examining a client's ears and notes that right ear is occluded with wax.The nurse would choose which of the following to remove the earwax?
1)Irrigation with warm mineral oil,peroxide,followed by warm water
2)A sharp instrument to break up the ear wax
3)Irrigation with a cold solution
4)A cerumen spoon to remove the wax
5)Irrigation with warm sudsy water

Question 21

The nurse is performing the Weber test.The nurse documents that the sound lateralized to the client's right ear.The student nurse observing the assessment asks the nurse about the meaning of this documentation.Which of the following is the nurse's best response?
1)"This just means that I am unable to visualize the client's tympanic membrane."
2)"It refers to the client's inability to hear whispered statements."
3)"The client is able to hear bone-conducted sound longer than air conducted sound."
4)"The client is able to hear bone-conducted sound better through the impaired ear."

Question 22

The nurse is conducting a hearing assessment on an older adult client with impacted cerumen noted in the right ear canal.When performing the Weber test,the nurse would expect to learn which of the following?
1)Air conduction is longer than bone conduction.
2)Bone conduction is longer than air conduction.
3)Sound lateralized to the right ear.
4)The client is unable to maintain balance while standing.
5)The 4 year old placed a pea into his nose during lunch.

Question 23

The nurse is assessing the oral mucosa of a pregnant female and notes enlargement of the gums.The client states that regular oral hygiene is performed and that she does not understand why this has occurred.Which of the following is the nurse's best response?
1)"You may have oral cancer."
2)"You are experiencing a normal change during pregnancy."
3)"You may have leukoplakia."
4)"You need to decrease the frequency of your oral hygiene."

Question 24

The nurse is assessing the ears,nose and mouth of an Asian client with a student nurse.Which of the following statements made by the nurse to the student nurse about cultural differences is accurate?
1)"Asians are more likely to experience greater difficulty with otitis media than people from other cultures."
2)"Sometimes in Asians and Native Americans,their ear wax looks dry and dark."
3)"Asians have a higher risk of having issues associated with cleft lips and cleft palates."
4)"Asians have a high incidence of tooth decay."

Question 25

The nurse is discharging an 11-month-old child who was brought to the emergency room for the treatment of an ear infection and fever.The nurse would include which of the following statements in the discharge teaching to the parents?
1)"The baby's last bottle before bedtime should only contain water."
2)"It is important not to prop the baby's bottle during feeding."
3)"You must rinse the baby's mouth right after the baby falls asleep."
4)"You must perform oral hygiene more frequently throughout the day."
5)"The last bottle of the evening should not be given just before the baby goes to sleep."

Question 26

The nurse is assessing several children in a pediatric clinic.Which of the following children might be experiencing delayed development?
1)The 6-year-old child has lost 2 deciduous teeth.
2)The 26-month-old child has one baby tooth.
3)The 4-month-old infant is drooling.
4)The 2-month-old infant's salivary glands are not producing saliva.

Question 27

During the focused interview,the client provides information to the nurse regarding her daughter's recent diagnosis with cancer.The client is exhibiting clinical manifestations associated with anxiety.During the physical assessment,which of the following findings might be expected?
1)The client complains of pain when the tragus is gently manipulated.
2)The client has several small ulcers on her lip.
3)Pale nasal mucosa
4)Small sores are noted within the mouth.
5)Perforated nasal septum

Question 28

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips.Based on this finding,the nurse would implement which of the following actions first?
1)Administer IV fluids.
2)Provide oral hygiene.
3)Administer oxygen.
4)Provide a warm drink.

Question 29

The nurse is assessing the oral cavity of a client and notes a blackish,furry-looking coating on the tongue.Which of the following questions would be appropriate for the nurse to include when obtaining further assessment data?
1)"Have you eaten licorice lately?"
2)"How often do you brush your tongue?"
3)"Have you recently taken antibiotics?"
4)"Have you ever had this happen before?"

Question 30

The client admits to cleaning his ears with a cotton-tipped applicator.As a consequence,the client has developed impacted cerumen and unilateral hearing loss.As the nurse prepares the client's plan of care,which of the following nursing diagnoses is most applicable?
1)Acute pain
2)Knowledge deficit
3)Acute confusion
4)Unilateral neglect

Question 31

An elderly client says,"I can't seem to hear as well as I could when I was younger." The nurse suspects this client is experiencing which of the following disorders?
1)Presbycusis
2)Mastoiditis
3)Otitis media
4)Otitis externa

Question 32

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.The nurse would suspect which of the following in this situation?
1)Rhinitis
2)Perforated septum
3)Previous epistaxis
4)Nasal polyps