NOSE
The medical term for nosebleeds is __________.
Epistaxis
Your ______ is the little fleshy hanging ball in the back of your throat. As part of your soft palate, it helps prevent food and liquid from going up your nose when you swallow.
ANS: Uvula
What is the tissue that connects the tongue to the floor of the mouth called?
a. Uvula
b. Palate
c. Papillae
d. Frenulum
ANSWER: 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 isthe arching roof of the mouth.
Papillae are the rough, bumpy elevations on the tongue's dorsal surface.
In addition to initiating digestion of food, this fluid helps clean and protects mucosa.
ANS: Saliva
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).
A normal finding when palpating the sinus areas is for the patient to feel firm pressure, not no sensation at all, pain during palpation, or pain behind the eyes.
Sinus areas that are tender to palpation may indicate chronic allergies or an acute infection (sinusitis). Feeling firm pressure but no pain is a normal
finding.
You assess a patient's tonsil and find it appropriate to score them as a +4. Are you concerned? Why or why not?
An enlarged tongue (macroglossia) may accompany:
A cleft palate.
B hairy tongue.
C Down syndrome.
D fissured tongue.
ANSWER: C
Down syndrome
During an examination of the oral cavity, what technique by the nurse is appropriate to examine the tongue?
a. use a penlight and tongue depressor to retract the
lips
b. use a square gauze pad to hold the client's tongue
to each side
c. put on gloves and retract the client's lips and
cheeks
d. ask the client to stick the tongue out between the
lips
ANS: B
Use a square gauze pad to get better traction to hold the client's tongue and swing to each side.
A woman who is in the second trimester of pregnancy mentions that she has had "more
nosebleeds than ever" since she became pregnant. What is the likely reason for this?
a. Inappropriate use of nasal sprays
b. A problem with the patient's coagulation system
c. Increased susceptibility to colds and nasal
irritation
d. Increased vascularity in the upper respiratory
tract as a result of the pregnancy
ANS: D
Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity
in the upper respiratory tract.
Inappropriate use of nasal sprays often causes rebound congestion or swelling, but not usually nosebleeds.
Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. So, this patient's nose bleeds are more likely to be due to the increased vascularity in the upper respiratory tract than to a problem with the coagulation system or an increased susceptibility to colds and nasal irritation.
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
a. Rubella
b. Leukoplakia
c. Rheumatic fever
d. None of the above
ANS: C
Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal.
Rheumatic fever may develop if strep throat is not treated properly. It usually takes about 1 to 5 weeks after one of these infections for rheumatic fever to develop. It more commonly affects children ages 5-15 years of age.
Rheumatic fever is a condition that can inflame or make the heart, joints, brain, and skin swell. Rheumatic fever is thought to be an immune response to an earlier infection.
Rubella is measles which usually presents as a skin rash that does not result from strep throat.
Leukoplakia is a condition that creates white patches on your tongue, gums or the inside of your cheeks that does not result from strep throat, but more likely smoking.
When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?
a. Teeth appearing shorter
b. Tongue that looks smoother in appearance
c. Buccal mucosa that is beefy red in appearance
d. Small, painless lump on the dorsum of the tongue
ANS: B
In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.
A 32-year-old woman has a 4-day history of sore throat and difficulty swallowing. The nurse observes tonsils covered with yellow patches. The tonsils are so large that they fill the entire oropharynx and appear to be touching. How does the nurse document thee findings?
A - "Tonsils yellow and swollen."
B - "Enlarged tonsils 4+ with yellow exudates."
C - "Strep infection to tonsils with 3+ swelling."
D - "1+ edema of tonsils with pus."
ANS: B - "Enlarged tonsils 4+ with yellow exudates."
You are scoring the swelling of the tonsils appropriately and mentioned the color of the fluid that is present.
A. Does not score the tonsil swelling
C. Insinuates that strep is present without test
results
D. Did not adequately score the swelling of the
tonsils or mention the color of the exudate
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 nurse's 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 don't 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.
Tilting your head back can cause blood to go into your lungs. A cold compress can be used to constrict blood vessels, but the pressure of pinching the vessels are more likely to aid with bleeding.
ANS: Hard Palate
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.
d. Side effects from nausea medication.
ANS: A
Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.
The nurse is having difficulty visualizing the uvula because of the client's sensitive gag reflex. Which nursing action will facilitate visualization of the client's uvula?
A. Ask the client to say "aaah" after opening the
mouth
B. Place the tongue depressor on the tip of the
tongue
C. Place the tongue depressor slightly off center
D. Hold the client's tongue to one side of the mouth
ANS: C
Place the tongue depressor slightly off center so the patient can still say ahh while you move away the tongue to visualize.
During a checkup, a 22-year-old woman tells the nurse that she uses an decongestant over-the-counter nasal spray because of her allergies and congestion. She also states that it does not work as well as it used to when she first started using it. The best response by the nurse would be:
a. "You should never use over-the-counter nasal sprays be cause of the risk of addiction."
b. "You should try switching to another brand of medication to prevent this problem."
c. "Continuing to use this spray is important to keep your allergies under control."
d. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."
ANS: D
The misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, which is a common problem.
This is common medical term. It is used to describe a bad smell upon a throat/mouth assessment. It usually has a local cause such as poor oral hygiene and decaying food debris between the teeth or lodged into the tonsils.
ANS: Halitosis
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.
A client who is brought to the emergency department in a confused state. Upon examination of the client's mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process?
a. small-bowel obstruction
b. respiratory infection
c. diabetic ketoacidosis
d. end-stage liver disease
ANS: C - Diabetic Ketoacidosis
Diabetic ketoacidosis has a sweet, fruity breath odor. This happens when the body cannot use sugar for fuel and begins using fat instead. This causes an acid called ketones to build up in the body. Excess ketones in the body can cause a sweet, fruity smell and taste in the mouth.