The nurse is reviewing a client's electronic health record before assessing her mouth. Which of the following diagnoses would the nurse recognize as an indication for immediate medical follow-up?
C) Leukoplakia
In the course of the nurse's health interview, a client reports an occasional blockage in the upper portion of his nasal passage. What is the most pronounced effect that this will have on the client?
C) Impaired sense of smell
A client presents with a cluster of upper airway complaints that include rhinorrhea. Which area of assessment would yield the most pertinent information to the etiology of rhinorrhea?
D) History of allergies
The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. Which of the following would be most appropriate for the nurse to include?
B) Thoroughly chew small amounts of food with each mouthful.
When examining the mouth of an adult client with recent cognitive changes, the nurse notes a distinct bluish-black line along the client's gum line. Which action should be the nurse's priority?
A) Referring the client for further evaluation
While examining a client's mouth, the nurse notes the presence of fasciculations (fine tremors) of the client's tongue. How should the nurse best respond to this assessment finding?
C) Assess the client's cranial nerve function
A client has just been diagnosed with a sinus infection accompanied by large amounts of exudate. Which of the following assessment findings should the nurse anticipate along with this condition?
C) Crepitus over the maxillary sinuses
The nurse is inspecting a client's tonsils and notes that they make contact with the client's uvula. The nurse would document this finding as which of the following?
A) 3+
A decrease in tongue strength is noted on examination of a client. The nurse interprets this as indicating a problem with which cranial nerve?
A) XII
When examining a child who complains of a sore throat, the nurse notes swelling on either side of the child's oropharynx. The nurse would include which of the following when documenting this finding?
D) Enlarged palatine tonsils
The nurse is assessing an older adult client whose health problems include receding gums. The nurse notes gum ischemia and worn tooth surfaces. Which question would be most important for the nurse to ask?
A) ìHave you lost any teeth recently?î
During the health interview, the nurse notes that a client is a mouth breather. The client denies nasal congestion and has a healthy body mass index. Which of the following would be most important for the nurse to assess?
B) Checking for a deviated nasal septum
While performing an elderly client's admission assessment, the nurse notes the presence of deep tongue fissures. Which of the following responses should take priority?
B) Intravenous fluid replacement
The nurse assesses thick, white plaques on a client's tongue and hard palate. Which of the following nursing actions should the nurse do next?
C) Refer the client to a primary care provider for medication.
The nurse inspects a client's mouth and notes the presence of a bifid uvula. The nurse understands that this finding is most common in which ethnic group?
A) Native Americans
On inspection, the nurse observes a line across the tip of an 8-year-old client's nose. The nurse should consequently focus on which area of assessment?
D) Chronic allergies
A client has presented for care because of frequent sinus headaches. During transillumination of the frontal sinuses, a red glow is noted. The nurse should anticipate which of the following?
C) The headaches are most likely not from a sinus infection.
A group of students is reviewing information about the salivary glands and their secretions. The students demonstrate understanding of the information when they identify which of the following as components of saliva? Select all that apply.
B) Salts
D) Mucus
E) Amylase
The nurse has completed a focused assessment of a client's mouth, nose, and throat. Which of the following findings would a nurse interpret as being normal?
A) Pinkish, spongy soft palate
When assessing a client for possible oral cancer, the nurse should most closely inspect which area?
D) Area under the tongue
A nurse is integrating health promotion education into the assessment of a client's mouth, nose, and throat. What interview question is most likely to identify a risk factor for oral cancer?
C) ìDo you use tobacco, whether smoking or chewing?î
The nurse is assessing a client who enjoys good health overall but who has brought a complaint of chronic nasal congestion and recurrent nosebleeds. What interview question should the nurse prioritize?
C) ìHow often do you use over-the-counter nasal sprays?î
The nurse is interviewing an adult client in the context of a focused mouth, nose, sinus, and throat assessment. After asking the client about his history of environmental allergies, the client states, ìI'm pretty sure that I'm allergic to something, but I'm not exactly sure what triggers my allergies.î How can the nurse begin to identify the specific allergens that cause the man's symptoms?
D) Ask the client about the timing of his allergy symptoms.
An experienced nurse is aware that receding gums are an expected finding in some clients whereas in other clients this finding is abnormal. In which of the following clients would the nurse identify receding gums as an expected assessment finding?
B) A 77-year-old man who describes himself as being healthy
Assessment of a client's mouth reveals a lesion on the client's buccal membrane that is approximately 0.5 cm in diameter. On further questioning, the client states that the lesion has been present for 3 months and that it bleeds intermittently. How should the nurse follow up this assessment finding?
D) Refer the client to her primary care provider promptly.
A client has presented with ìa terrible head cold,î and the nurse is assessing for signs and symptoms of sinusitis. The nurse should utilize what assessment techniques? Select all that apply.
A) Palpation
D) Percussion
E) Transillumination
The nurse is assessing the sinuses of a client who exhibits many of the clinical characteristics of sinusitis. When percussing the client's sinuses, what assessment finding would most strongly suggest sinusitis?
B) Pain on percussion
The nurse is caring for a client who has been experiencing dysphagia secondary to a stroke. What risk nursing diagnosis should the nurse associate with this health problem?
C) Risk for aspiration related to decreased swallowing ability
A medical nurse is preparing to administer a topical antifungal medication to a client who has just been diagnosed with an oral candida infection (thrush). On inspection of the patient's tongue, the nurse should anticipate what appearance?
D) Thick, white plaques on the tongue surface
The nurse is assessing the characteristics and positioning of the client's uvula, which deviates asymmetrically when the nurse has the client say ìaaah.î This finding should prompt the nurse to focus on which of the following during subsequent assessment?