Exam 16: Ears, Nose, Mouth, and Throat

The nurse is triaging a client and notes pallor and cyanosis of the oral cavity and lips. Which action by the nurse is the priority based on the assessment data?

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?

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?

The nurse is discharging an infant who was brought to the emergency department for the treatment of an ear infection and fever. Which statements will the nurse include in the discharge teaching?

During the focused interview, the client confides in the nurse issues with anxiety. During the physical assessment, which findings support the presence of anxiety?

A client who is having difficulty maintaining equilibrium is unable to ambulate without pushing a wheelchair or using a walker. Which part of the ear is not functioning completely based on this assessment data?

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?

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?

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 response by the nurse is the most appropriate?

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 nursing diagnosis is most applicable?

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?

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?

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?

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?