TB-Chapter 17 Nose, Mouth, and Throat PDF

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PHYSICAL EXAMINATION AND HEALTH ASSESSMENT 8TH EDITION JARVIS TEST BANK

TestBank-PhysicalExaminationandHealthAssessment8e(byJarvis)

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Chapter17:Nose,Mouth,andThroat MULTIPLECHOICE 1.Theprimarypurposeoftheciliatedmucousmembraneinthenoseisto: a.

Warmtheinhaledair.

b.

Filteroutdustandbacteria.

c.

Filtercoarseparticlesfrominhaledair.

d.

Facilitatethemovementofairthroughthenares.

ANS:B Thenasalhairsfilterthecoarsestmatterfrominhaledair,whereasthemucousblanketfiltersoutdustand bacteria.Therichbloodsupplyofthenasalmucosawarmstheinhaledair. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 2.Theprojectionsinthenasalcavitythatincreasethesurfaceareaarecalledthe: a.

Meatus.

b.

Septum.

c.

Turbinates.

d.

Kiesselbachplexus.

NURSINGTB.COM

ANS:C Thelateralwallsofeachnasalcavitycontainthreeparallelbonyprojections:thesuperior,middle,andinferior turbinates.Theseincreasethesurfacearea,makingmorebloodvesselsandmucousmembraneavailableto warm,humidify,andfiltertheinhaledair. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 3.Thenurseisreviewingthedevelopmentofthenewborninfant.Regardingthesinuses,whichstatementis trueinrelationtoanewborninfant? a.

Sphenoidsinusesarefullsizeatbirth.

b.

Maxillarysinusesreachfullsizeafterpuberty.

NURSINGTB.COM

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c.

Frontalsinusesarefairlywelldevelopedatbirth.

d.

Maxillaryandethmoidsinusesaretheonlysinusespresentatbirth.

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ANS:D Onlythemaxillaryandethmoidsinusesarepresentatbirth.Thesphenoidsinusesareminuteatbirthand developafterpuberty.Thefrontalsinusesareabsentatbirth,arefairlywelldevelopedatage7to8years,and reachfullsizeafterpuberty. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 4.Thetissuethatconnectsthetonguetothefloorofthemouthisthe: a.

Uvula.

b.

Palate.

c.

Papillae.

d.

Frenulum. NURSINGTB.COM

ANS:D

Thefrenulumisamidlinefoldoftissuethatconnectsthetonguetothefloorofthemouth.Theuvulaisthefree projectionhangingdownfromthemiddleofthesoftpalate.Thepalateisthearchingroofofthemouth. Papillaearetherough,bumpyelevationsonthetonguesdorsalsurface. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 5.Thesalivaryglandthatisthelargestandlocatedinthecheekinfrontoftheearisthe_________gland. a.

Parotid

b.

Stensens

c.

Sublingual

d.

Submandibular

ANS:A Themouthcontainsthreepairsofsalivaryglands.Thelargest,theparotidgland,lieswithinthecheeksinfront oftheearextendingfromthezygomaticarchdowntotheangleofthejaw.TheStensensduct(notgland) drainstheparotidglandontothebuccalmucosaoppositethesecondmolar.Thesublingualglandislocated withinthefloorofthemouthunderthetongue.Thesubmandibularglandliesbeneaththemandibleattheangle

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ofthejaw. DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:General 6.Inassessingthetonsilsofa30yearold,thenursenoticesthattheyareinvoluted,granularinappearance, andappeartohavedeepcrypts.Whatiscorrectresponsetothesefindings? a.

Referthepatienttoathroatspecialist.

b.

Noresponseisneeded;thisappearanceisnormalforthetonsils.

c.

Continuewiththeassessment,lookingforanyotherabnormalfindings.

d.

Obtainathroatcultureonthepatientforpossiblestreptococcal(strep)infection.

ANS:B Thetonsilsarethesamecolorasthesurroundingmucousmembrane,althoughtheylookmoregranularand theirsurfaceshowsdeepcrypts.Tonsillartissueenlargesduringchildhooduntilpubertyandtheninvolutes. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare NURSINGTB.COM 7.Thenurseisobtainingahealthhistoryona3-month-oldinfant.Duringtheinterview,themotherstates,I thinksheisgettingherfirsttoothbecauseshehasstarteddroolingalot.Thenursesbestresponsewouldbe:

a.

Youreright,droolingisusuallyasignofthefirsttooth.

b.

Itwouldbeunusualfora3montholdtobegettingherfirsttooth.

c.

Thiscouldbethesignofaproblemwiththesalivaryglands.

d.

Sheisjuststartingtosalivateandhasntlearnedtoswallowthesaliva.

ANS:D Intheinfant,salivationstartsat3months.Thebabywilldroolforafewmonthsbeforelearningtoswallowthe saliva.Thisdroolingdoesnotheraldtheeruptionofthefirsttooth,althoughmanyparentsthinkitdoes. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 8.Thenurseisassessingan80-year-oldpatient.Whichofthesefindingswouldbeexpectedforthispatient? a.

Hypertrophyofthegums

b.

Increasedproductionofsaliva

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c.

Decreasedabilitytoidentifyodors

d.

Finerandlessprominentnasalhair

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ANS:C Thesenseofsmellmaybereducedbecauseofadecreaseinthenumberofolfactorynervefibers.Nasalhairs growcoarserandstifferwithaging.Thegumsmayrecedewithaging,nothypertrophy,andsalivaproduction decreases. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:HealthPromotionandMaintenance 9.Thenurseisperforminganoralassessmentona40-year-oldBlackpatientandnoticesthepresenceofa1 cm,nontender,grayish-whitelesionontheleftbuccalmucosa.Whichoneofthesestatementsistrue?This lesionis: a.

Leukoedemaandiscommonindark-pigmentedpersons.

b.

Theresultofhyperpigmentationandisnormal.

c.

Toruspalatinusandwouldnormallybefoundonlyinsmokers.

d.

Indicativeofcancerandshouldbeimmediatelytested.

NURSINGTB.COM

ANS:A Leukoedema,agrayish-whitebenignlesionoccurringonthebuccalmucosa,ismostoftenobservedinBlacks. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 10.Whileobtainingahealthhistory,apatienttellsthenursethathehasfrequentnosebleedsandasksthebest waytogetthemtostop.Whatwouldbethenursesbestresponse? a.

Whilesittingup,placeacoldcompressoveryournose.

b.

Situpwithyourheadtiltedforwardandpinchyournose.

c.

Justallowthebleedingtostoponitsown,butdontblowyournose.

d.

Lieonyourbackwithyourheadtiltedbackandpinchyournose.

ANS:B Withanosebleed,thepersonshouldsitupwiththeheadtiltedforwardandpinchthenosebetweenthethumb andforefingerfor5to15minutes.

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DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 11.A92-year-oldpatienthashadastroke.Therightsideofhisfaceisdrooping.Thenursemightalsosuspect whichoftheseassessmentfindings? a.

Epistaxis

b.

Rhinorrhea

c.

Dysphagia

d.

Xerostomia

ANS:C Dysphagiaisdifficultywithswallowingandmayoccurwithavarietyofdisorders,includingstrokeandother neurologicdiseases.Rhinorrheaisarunnynose,epistaxisisabloodynose,andxerostomiaisadrymouth. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 12.Whileobtainingahealthhistoryfromthemotherofa1-year-oldchild,thenursenoticesthatthebabyhas hadabottleinhismouththeentiretime.Themotherstates,Itmakesagreatpacifier.Thebestresponsebythe NURSINGTB.COM nursewouldbe: a.

Youreright.Bottlesmakeverygoodpacifiers.

b.

Usingabottleasapacifierisbetterfortheteeththanthumb-sucking.

c.

Itsokaytouseabottleaslongasitcontainsmilkandnotjuice.

d.

Prolongeduseofabottlecanincreasetheriskfortoothdecayandearinfections.

ANS:D Prolongedbottleuseduringthedayorwhengoingtosleepplacestheinfantatriskfortoothdecayandmiddle earinfections. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:HealthPromotionandMaintenance 13.A72-year-oldpatienthasahistoryofhypertensionandchroniclungdisease.Animportantquestionforthe nursetoincludeinthehealthhistorywouldbe: a.

Doyouuseafluoridesupplement?

b.

Haveyouhadtonsillitisinthelastyear?

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c.

Atwhatagedidyougetyourfirsttooth?

d.

Haveyounoticedanydrynessinyourmouth?

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ANS:D Xerostomia(drymouth)isasideeffectofmanydrugstakenbyolderpeople,includingantidepressants, anticholinergics,antispasmodics,antihypertensives,antipsychotics,andbronchodilators. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 14.Thenurseisusinganotoscopetoassessthenasalcavity.Whichofthesetechniquesiscorrect? a.

Insertingthespeculumatleast3cmintothevestibule

b.

Avoidingtouchingthenasalseptumwiththespeculum

c.

Gentlydisplacingthenosetothesidethatisbeingexamined

d.

Keepingthespeculumtipmedialtoavoidtouchingthefloorofthenares

ANS:B

NURSINGTB.COM

Thecorrecttechniqueforusinganotoscopeistoinserttheapparatusintothenasalvestibule,avoidingpressure onthesensitivenasalseptum.Thetipofthenoseshouldbeliftedupbeforeinsertingthespeculum. DIF:CognitiveLevel:Understanding(Comprehension) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 15.Thenurseisperforminganassessmentona21-year-oldpatientandnoticesthathisnasalmucosaappears pale,gray,andswollen.Whatwouldbethemostappropriatequestiontoaskthepatient? a.

Areyouawareofhavinganyallergies?

b.

Doyouhaveanelevatedtemperature?

c.

Haveyouhadanysymptomsofacold?

d.

Haveyoubeenhavingfrequentnosebleeds?

ANS:A Withchronicallergies,themucosalooksswollen,boggy,pale,andgray.Elevatedbodytemperature,colds,an nosebleedsdonotcausethesemucosalchanges. DIF:CognitiveLevel:Applying(Application)

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MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 16.Thenurseispalpatingthesinusareas.Ifthefindingsarenormal,thenthepatientshouldreportwhich sensation? a.

Nosensation

b.

Firmpressure

c.

Painduringpalpation

d.

Painsensationbehindeyes

ANS:B Thepersonshouldfeelfirmpressurebutnopain.Sinusareasaretendertopalpationinpersonswithchronic allergiesoranacuteinfection(sinusitis). DIF:CognitiveLevel:Remembering(Knowledge) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 17.Duringanoralassessmentofa30-year-oldBlackpatient,thenursenoticesbluishlipsandadarklinealong thegingivalmargin.Whatactionwouldthenurseperforminresponsetothisfinding? a.

Checkthepatientshemoglobinforanemia. NURSINGTB.COM

b.

Assessforothersignsofinsufficientoxygensupply.

c.

Proceedwiththeassessment,knowingthatthisappearanceisanormalfinding.

d.

Askifhehasbeenexposedtoanexcessiveamountofcarbonmonoxide.

ANS:C SomeBlacksmayhavebluishlipsandadarklineonthegingivalmargin;thisappearanceisanormalfinding. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:SafeandEffectiveCareEnvironment:ManagementofCare 18.Duringanassessmentofa20-year-oldpatientwitha3-dayhistoryofnauseaandvomiting,thenurse noticesdrymucosaanddeepverticalfissuresinthetongue.Thesefindingsarereflectiveof: a.

Dehydration.

b.

Irritationbygastricjuices.

c.

Anormaloralassessment.

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d.

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Sideeffectsfromnauseamedication.

ANS:A Drymouthoccurswithdehydrationorfever.Thetonguehasdeepverticalfissures. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 19.A32-year-oldwomanisattheclinicforlittlewhitebumpsinmymouth.Duringtheassessment,thenurse notesthatshehasa0.5cmwhite,nontenderpapuleunderhertongueandoneonthemucosaofherrightcheek Whatwouldthenursetellthepatient? a.

Thesespotsindicateaninfectionsuchasstrepthroat.

b.

Thesebumpscouldbeindicativeofaseriouslesion,soIwillreferyoutoaspecialist.

c.

Thisconditioniscalledleukoplakiaandcanbecausedbychronicirritationsuchaswithsmoking.

d.

ThesebumpsareFordycegranules,whicharesebaceouscystsandarenotaseriouscondition.

ANS:D Fordycegranulesaresmall,isolatedwhiteoryellowpapulesonthemucosaofthecheek,tongue,andlips. NURSINGTB.COM Theselittlesebaceouscystsarepainlessandarenotsignificant.Chalky,whiteraisedpatcheswouldindicate leukoplakia.Instrepthroat,theexaminerwouldseetonsilsthatarebrightred,swollen,andmayhaveexudates orwhitespots. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 20.A10yearoldisattheclinicforasorethroatthathaslasted6days.Whichofthesefindingswouldbe consistentwithanacuteinfection? a.

Tonsils1+/1-4+andpink;thesamecolorastheoralmucosa

b.

Tonsils2+/1-4+withsmallplugsofwhitedebris

c.

Tonsils3+/1-4+withlargewhitespots

d.

Tonsils3+/1-4+withpalecoloring

ANS:C Withanacuteinfection,tonsilsarebrightredandswollenandmayhaveexudateorlargewhitespots.Tonsils areenlargedto2+,3+,or4+withanacuteinfection. DIF:CognitiveLevel:Understanding(Comprehension)

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MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 21.Immediatelyafterbirth,thenurseisunabletosuctionthenaresofanewborn.Anattemptismadetopassa catheterthroughbothnasalcavitieswithnosuccess.Whatshouldthenursedonext? a.

Attempttosuctionagainwithabulbsyringe.

b.

Waitafewminutes,andtryagainoncetheinfantstopscrying.

c.

Recognizethatthissituationrequiresimmediateintervention.

d.

Contactthephysiciantoscheduleanappointmentfortheinfantathisorhernexthospitalvisit.

ANS:C Determiningthepatencyofthenaresintheimmediatenewbornperiodisessentialbecausemostnewbornsare obligatenosebreathers.Naresblockedwithamnioticfluidaregentlysuctionedwithabulbsyringe.If obstructionissuspected,thenasmalllumen(5to10Fr)catheterispasseddowneachnaristoconfirmpatency Theinabilitytopassacatheterthroughthenasalcavityindicateschoanalatresia,whichrequiresimmediate intervention. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 22.Thenursenoticesthatthemotherofa2-year-oldboybringshimintotheclinicquitefrequentlyforvarious NURSINGTB.COM injuriesandsuspectstheremaybesomechildabuseinvolved.Duringaninspectionofhismouth,thenurse shouldlookfor: a.

Swollen,redtonsils.

b.

Ulcerationsonthehardpalate.

c.

Bruisingonthebuccalmucosaorgums.

d.

Smallyellowpapulesalongthehardpalate.

ANS:C Thenurseshouldnoticeanybruisingorlacerationonthebuccalmucosaorgumsofaninfantoryoungchild. Traumamayindicatechildabusefromaforcedfeedingofabottleorspoon. DIF:CognitiveLevel:Applying(Application) MSC:ClientNeeds:PhysiologicIntegrity:ReductionofRiskPotential 23.Thenurseisassessinga3yearoldfordrainagefromthenose.Onassessment,apurulentdrainagethathas averyfoulodorisnotedfromtheleftnarisandnodrainageisobservedfromtherightnaris.Thechildis afebrilewithnoothersymptoms.Whatshouldthenursedonext? a.

Refertothephysicianforanantibioticorder.

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b.

Havethemotherbringthechildbackin1week.

c.

Performanotoscopicexaminationoftheleftnares.

d.

Tellthemotherthatthisdrainageisnormalforachildofthisage.

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ANS:C Childrenarepronetoputanobjectupthenose,producingunilateralpurulentdrainagewithafoulodor. Becausesomeriskforaspirationexists,removalshouldbeprompt. DIF:CognitiveLevel:Analyzing(Analysis) MSC:ClientNeeds:PhysiologicIntegrity:PhysiologicAdaptation 24.Duringanassessmentofa26yearoldattheclinicforasp...