Question 1

The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? Select all that apply.

Accepted Answer

Streptomycin, aspirin, and neomycin are known to be ototoxic, meaning they can cause hearing loss and tinnitus as side effects.

Question 2

The client has developed anosmia. The nurse educates the client about the possible causes of this condition. Which topics are appropriate for the nurse to include in the teaching session with the client? Select all that apply.

Accepted Answer

Anosmia can be linked to heredity, a zinc-deficient diet, and neurological problems. Gingivitis and dental caries are not common causes of anosmia.

Question 3

The nursing is performing an otoscopic examination on an adult client and is unable to visualize the tympanic membrane. Which action by the nurse is appropriate in this situation?

Accepted Answer

For adults, the correct technique to straighten the ear canal during an otoscopic examination is to pull the pinna up and back. This action helps to align the ear canal, allowing for better visualization of the tympanic membrane.

Question 4

The nurse is preparing to assess the ventral surface of the tongue. Which should the nurse anticipate to find?

Accepted Answer

The ventral surface of the tongue is smooth and vascular, unlike the dorsal surface which has papillae.

Question 5

The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract?

Accepted Answer

The turbinates, also known as nasal conchae, are responsible for filtering, moistening, and warming the air that enters the lower portion of the respiratory tract. This process helps to protect the lungs from irritants and pathogens.

Question 6

The emergency department 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. Which interpretation of the assessment data by the nurse is the most appropriate?

Accepted Answer

The inability to breathe through one nostril, especially in the context of recent cough and nasal congestion, suggests severe nasal inflammation or obstruction. This could be due to a variety of causes including infection, foreign body, or severe congestion.

Question 7

A client asks the nurse what part of the ears becomes blocked with pressure when they travel on an airplane. Which structure of the ear should the nurse be prepared to discuss?

Accepted Answer

The answer of A client asks the nurse what part...

Question 8

During the focused interview, the client admits to regularly abusing cocaine. Which clinical manifestations support the regular use of cocaine? Select all that apply.

Accepted Answer

The answer of During the focused interview, the client admits...

Question 9

Which structure attaches the tongue to the floor of the mouth?

Accepted Answer

The frenulum is a small fold of tissue that secures or restricts the motion of a mobile organ in the body. In the context of the tongue, the lingual frenulum attaches the tongue to the floor of the mouth, allowing for movement but restricting its range to enable proper function in speech and eating.

Question 10

The nurse is assessing the tympanic membrane of a client and notes the presence of a darkened area. Based on this assessment data, which does the nurse suspect?

Accepted Answer

A darkened area on the tympanic membrane may indicate recent trauma, such as a perforation or bleeding, rather than infection or blockage.

Question 11

The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include?

Accepted Answer

Ulcerations on the lip or under the tongue are common manifestations of oral cancer, which can be caused by the use of chewing tobacco.

Question 12

The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Select all that apply.

Accepted Answer

The answer of The nurse is examining a client's ears...

Question 13

The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which interventions will the nurse implement?

Accepted Answer

A positive Romberg test indicates that the client has difficulty maintaining balance when their eyes are closed, suggesting issues with proprioception or vestibular function. Therefore, allowing the client to walk independently (A) could be unsafe. Obtaining an order for a catheter (B) might be unnecessary unless there are other indications, as it can increase the risk of urinary tract infections. Limiting fluid intake (C) could lead to dehydration and is not directly related to assisting with balance issues during elimination. Providing a bedside commode (D) is the safest option to meet the client's elimination needs while minimizing the risk of falls.

Question 14

A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Select all that apply.

Accepted Answer

The nurse should assess for any underlying bleeding disorders (A), check blood pressure to rule out hypertension as a cause (C), and inquire about recent nasal drainage to rule out other causes like a cerebrospinal fluid leak (E).

Question 15

A young mother brings an infant to the pediatric clinic. The infant has had a fever and is pulling at the left ear. Based on this data, which disorder does the nurse suspect?

Accepted Answer

The symptoms of fever and pulling at the ear are classic indicators of otitis media, which is an infection of the middle ear. This is a common condition in infants and young children.

Question 16

The client has been brought via ambulance to the emergency department (ED)following a motor vehicle accident. The nurse notes that the client's ear is draining clear fluid. Which is the priority nursing action?

Accepted Answer

The priority nursing action is to test the drainage for glucose because clear fluid draining from the ear following a head injury may indicate a cerebrospinal fluid (CSF) leak, which is a serious condition requiring immediate attention. Testing the fluid for glucose can help differentiate CSF from other types of ear drainage, as CSF typically contains glucose.

Question 17

The nurse is performing a focused interview with a client who has been cleaning the ears with a cotton-tipped applicator. Which complications of this practice will the nurse include in the teaching session for this client? Select all that apply.

Accepted Answer

The answer of The nurse is performing a focused interview...

Question 18

A client with recent cerebrovascular accident (CVA)is no longer able to smell. Which cranial nerve assessment should the nurse anticipate to include in the documentation?

Accepted Answer

Cranial nerve I, also known as the olfactory nerve, is responsible for the sense of smell. A cerebrovascular accident (CVA) affecting this nerve can lead to an inability to smell.

Question 19

A client tells the nurse they are experiencing pain and noticed some drainage from their left ear. Which objective finding indicates the client may have developed acute otitis media?

Accepted Answer

Yellowish-reddish drainage from the ear can indicate acute otitis media, suggesting the presence of infection and inflammation.

Question 20

A client presents in the healthcare provider's office with complaints of headache and malaise. During the assessment, the nurse notes the client is experiencing severe pain when palpating behind the ears. Based on this data, which diagnosis does the nurse anticipate?

Accepted Answer

Mastoiditis is an infection of the mastoid bone of the skull, which is located just behind the ear. Severe pain upon palpation in this area is a classic symptom of mastoiditis, distinguishing it from the other options listed.

Quiz 15: Ears, Nose, Mouth, and Throat