Question 1

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?

Accepted Answer

Lateralizing to the impaired ear on the Weber test means the client hears bone-conducted sound better through the impaired ear.

Question 2

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?

Accepted Answer

The Weber test is a quick screening test for hearing. It can detect unilateral (one-sided) conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss). When a tuning fork is placed on the center of the forehead, the sound should be heard equally in both ears. However, with impacted cerumen (earwax) blocking the ear canal, sound waves are blocked from passing through the ear normally, which can cause conductive hearing loss. In such cases, the sound from the tuning fork will lateralize, or seem louder, in the ear with the blockage (in this case, the right ear) because the body conducts the sound vibrations directly to the inner ear on that side, bypassing the blockage in the outer ear canal.

Question 3

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?

Accepted Answer

Enlargement of the gums is a normal change during pregnancy due to hormonal changes that increase blood flow to the gums. Option A is not appropriate as it instills fear and is not a likely reason for the gum enlargement. Option C is not appropriate because leukoplakia would present as white patches on the mucosa, not gum enlargement. Option D is not appropriate as good oral hygiene is important during pregnancy to prevent complications such as gingivitis.

Question 4

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?

Accepted Answer

This statement is accurate. Different cultures can have variations in the appearance of ear wax, and dry and dark ear wax is common in Asians and Native Americans. The other statements are either inaccurate (A and C) or too broad/generalized (D).

Question 5

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?

Accepted Answer

Choice B - "It is important not to prop the baby's bottle during feeding" is important to mention to prevent choking and also to ensure that the baby develops good feeding habits.
Choice E - "The last bottle of the evening should not be given just before the baby goes to sleep" is important to mention to prevent tooth decay and ear infections from the pooling of formula/breast milk in the mouth while the baby is lying down asleep.

Question 6

The nurse is assessing several children in a pediatric clinic.Which of the following children might be experiencing delayed development?

Accepted Answer

A 26-month-old child typically has more than one baby tooth. Delayed tooth eruption can be a sign of developmental delay.

Question 7

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?

Accepted Answer

The answer of During the focused interview,the client provides information...

Question 8

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?

Accepted Answer

Pallor and cyanosis of the oral cavity and lips suggest inadequate oxygenation. Administering oxygen would be the priority intervention to address this issue. Providing oral hygiene, administering IV fluids, or providing a warm drink may be appropriate interventions later if deemed necessary, but they do not address the immediate issue of inadequate oxygenation.

Question 9

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?

Accepted Answer

A blackish, furry-looking coating on the tongue can be indicative of a condition known as "black hairy tongue," which can occur after antibiotic use due to changes in the normal bacteria or yeast in the mouth.

Question 10

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?

Accepted Answer

The most applicable nursing diagnosis is knowledge deficit, as the client's use of a cotton-tipped applicator for ear cleaning has led to the development of impacted cerumen and hearing loss. The client may benefit from education on proper ear cleaning techniques to prevent future complications. Acute pain, acute confusion, and unilateral neglect are not the most appropriate nursing diagnoses for this situation.

Question 11

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?

Accepted Answer

Presbycusis is the gradual loss of hearing in both ears that occurs as people age. It is the most common cause of age-related hearing loss.

Question 12

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?

Accepted Answer

The presence of a watery discharge, sneezing, and congestion suggests inflammation of the nasal mucosa, or rhinitis. Perforated septum, previous epistaxis, and nasal polyps would not typically present with these symptoms.

Quiz 14: Ears, Nose, Mouth Throat