Question 1

An older adult client says, "I can't seem to hear as well as I could when I was younger." Which diagnosis does the nurse anticipate for this client?

Accepted Answer

A)   Presbycusis.
B)   Mastoiditis.
C)   Otitis media.
D)   Otitis externa. A

Question 2

The nurse is assessing the oral cavity of a client and notes a blackish, furry-looking coating on the tongue. Which question to the client is most appropriate based on this initial data?

Accepted Answer

A)   "Have you recently been ill?"
B)   "Do you chew tobacco?"
C)   "Have you recently taken antibiotics?"
D)   "Do you have a history of oral infections?" C

Question 3

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?

Accepted Answer

A)   Pull the pinna up and back and then reinsert the otoscope.
B)   Tell the client to move away from the speculum if they experience any pain as the otoscope is advanced.
C)   Reinsert the otoscope quickly and press against both sides of the inner auditory canal.
D)   Pull the pinna down and back and then reinsert the otoscope. A

Question 4

A client tells the nurse they are experiencing pain and noticed some drainage from their left ear. Which objective finding indicates the client may have developed acute otitis media?

Accepted Answer

A)   Reddened ear canal.
B)   Clear watery drainage.
C)   Mucus-like drainage.
D)   Yellowish-reddish drainage.

Question 5

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. Based on this data, which does the nurse suspect?

Accepted Answer

A)   Rhinitis.
B)   Perforated septum.
C)   Previous epistaxis.
D)   Nasal polyps.

Question 6

The client comes to the medical office complaining of tinnitus and bilateral hearing loss. After reviewing the client's medical record, the nurse determines that recently prescribed medication could be the cause for the assessment data. Which medications in the medical record could be responsible for the client's assessment data? Select all that apply.

Accepted Answer

A)   Streptomycin.
B)   Steroid inhalers.
C)   Aspirin.
D)   Neomycin.
E)   Acetaminophen.

Question 7

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?

Accepted Answer

A)   Produced by severe nasal inflammation or obstruction.
B)   Normal for a child.
C)   A result of chronic allergies.
D)   A result of sinusitis.

Question 8

The nurse educates the client about the major functions of the nose and sinuses. Which structure is specifically responsible for filtering, moistening, and warming air that enters the lower portion of the respiratory tract?

Accepted Answer

A)   Olfactory cells.
B)   Columella.
C)   Turbinates.
D)   Nares.

Question 9

The nurse observes white patches on the tympanic membrane. Which question should the nurse ask the client that is most relevant to the finding?

Accepted Answer

A)   "Do you have a history of ear infections?"
B)   "Have you experienced any recent hearing loss?"
C)   "Are you currently on any medication?"
D)   "Are you experiencing any pain in your ears?"

Question 10

The nurse is educating a group of adolescents about the risks of chewing tobacco. When describing the manifestation of oral cancer, which information will the nurse include?

Accepted Answer

A)   Bleeding and inflamed gums.
B)   Smooth and shiny tongue.
C)   Red, swollen tonsils.
D)   Ulcerations on the lip or under the tongue.

Question 11

The nurse is examining a client's ears and notes that right ear is occluded with wax. Which actions by the nurse are appropriate to facilitate removal of the cerumen from the client's ear? Select all that apply.

Accepted Answer

A)   Irrigating with warm mineral oil, peroxide, and flushing with warm water.
B)   Inserting a sharp instrument to break up the ear wax.
C)   Irrigating with a cold solution.
D)   Inserting a cerumen spoon to remove the wax.
E)   Irrigating with warm sudsy water.

Question 12

The nurse conducting the Rinne test notes that the client hears the bone conduction sound longer than the air conduction sound. Which should the nurse anticipate documenting?

Accepted Answer

A)   Possible conductive hearing loss.
B)   No hearing loss.
C)   Sensorineural hearing loss.
D)   Mixed hearing loss.

Question 13

A client arrives in the emergency department with complaints of intermittent nosebleeds over the past two days. Which are priority assessments for the nurse to implement when providing care to this client? Select all that apply.

Accepted Answer

A)   Request information from the client regarding increased propensity for bruising or bleeding.
B)   Assess the tonsils for redness or swelling.
C)   Obtain a blood pressure.
D)   Check for deviated septum.
E)   Request information from the client to determine if there was any recent thin, watery drainage from the nose.

Question 14

A client with recent cerebrovascular accident (CVA)is no longer able to smell. Which cranial nerve assessment should the nurse anticipate to include in the documentation?

Accepted Answer

A)   Cranial nerve I.
B)   Cranial nerve XII.
C)   Cranial nerve VIII.
D)   Cranial nerve VII.

Question 15

Which structure attaches the tongue to the floor of the mouth?

Accepted Answer

A)   Hard palate.
B)   Papillae.
C)   Frenulum.
D)   Alveoli sockets.

Question 16

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?

Accepted Answer

A)   Sinusitis.
B)   Mastoiditis.
C)   Chronic allergies.
D)   Anemia.

Question 17

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?

Accepted Answer

A)   Requesting information from the client regarding any chronic allergies.
B)   Testing the drainage for glucose.
C)   Asking the client if there have been recent middle ear infections.
D)   Irrigating the ear with warm mineral oil or peroxide and flushing with warm water.

Question 18

The nurse is preparing to assess the ventral surface of the tongue. Which should the nurse anticipate to find?

Accepted Answer

A)   Papillae.
B)   Parotid salivary glands.
C)   Smooth vascular tissue.
D)   Frenulum.

Question 19

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? Select all that apply.

Accepted Answer

A)   Commonly associated with gingivitis.
B)   Possibly linked to heredity.
C)   Related to a diet deficient in zinc.
D)   An indicator of a neurological problem.
E)   Caused by dental caries.

Question 20

The nurse observes that the Wharton's ducts are painful, reddened, and swollen. Which additional assessment finding should the nurse anticipate?

Accepted Answer

A)   Bleeding gums.
B)   Lesions.
C)   Dry mouth.
D)   Leukoplakia.

Exam 15: Ears, Nose, Mouth, and Throat