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NCLEX style questions from the Point
Terms in this set (26)
What technique should the nurse use to examine the sinuses of a client with a sinus infection?
Press up on the brow on each side of the nose to palpate the frontal sinus.
An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precautions should the nurse take to avoid an inaccurate result?
Instruct the client to remove upper dentures
A nurse is examining the nose of a client diagnosed with an upper respiratory tract infection. Which characteristics of the nasal mucosa should the nurse expect to find during assessment of a client with an upper respiratory tract infection
Red, swollen with purulent discharge
Which action but the nurse is appropriate to prevent the gag reflex during observation of the uvula?
depress the tongue slightly off center
During exam of the oral cavity, which technique by the nurse is appropriate to examine the tongue?
use a square gauze to hold the clients tongue to each side
A nurse examines a client with complaints of a sore throat and finds that the tonsils are enlarged and seen midway between the tonsillar pillars and uvula. Using a grading scale of 1+ to 4+, how should the nurse approximately document the tonsils?
2+
Which characteristic of the gums should the nurse expect to assess in a client who experiences an adverse effect of phenytoin treatment?
enlarged and reddened
Which assessment of the tongue should a nurse recognize as abnormal?
Red with loss of papillae-
indicative of vitamin b12 or niacin loss.
A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past 2 weeks. What additional information should the nurse ask this client?
Are you experiencing sinus pressure and congestion?
nurse inspects the gums and teeth of a middle aged adult and notices the presence of small brown spots on the chewing surfaces of several of the molar teeth. What question should the nurse ask the client to determine the cause of this finding?
Are you experiencing any tooth pain?
-may indicate tooth decay which may also cause pain with chewing
A client reports a 20 pack per year history of cigarette smoking. To assess this client for cancer, where should the nurse inspect the tongue?
both sides
The sides of the tongue are the most common area for carcinoma to occur
A client presents to the health care clinic with reports of a 3 day fever, sore throat and trouble swallowing. The nurse notes the client to be febrile with temperature 101.5 F, tonsils are 2+ and red, transillumination of the sinuses is normal. Which nursing diagnosis should the nurse confirm based on this data?
Acute pain
A client who is semiconscious is brought to the emergency department of a health care facility after being rescued from a fire. Which finding of the lips supports the diagnosis of carbon monoxide poisoning?
Reddish
A client is brought to the emergency department in a confused state. Upon examination of the clients mouth, the nurse detects a fruity odor to the breath. The nurse recognizes this finding as a characteristic of what disease process?
Diabetic Ketoacidosis
During assessment of the oral cavity, the nurse examines the salivary glands. Which area of the mouth should the nurse assess to inspect for the Wharton's ducts?
either side of the frenulum on the floor of the mouth
A Childs presents to the health care facility with new onset of a foul smelling, purulent drainage from the right care. The mother states that no other signs of upper respiratory tract infection are present. What is an appropriate action by the nurse?
Inspect the nostrils with an otoscope.
A nurse should assist a client to assume what position to best assess mouth, nose and sinuses?
sitting with the head erect and at eye level of the nurse
A nurse is working with a client from Asia who has just been diagnosed with oropharyngeal cancer. Which culture related risk factor should the nurse suspect with this client?
chewing betel nuts
A client has a sore throat and difficulty swallowing that has lasted for months. There are no lesions on the lips. The nurse suspects the client may have oropharyngeal cancer. Which of the following are risk factors the nurse should assess for in this client?
-Heavy alcohol use
-frequent pipe smoking
A client arrives complaining of nasal congestion, drainage of a thick, yellow discharge from the nose, difficulty breathing through the nose, headache and pressure in the forehead. The nurse suspects sinusitis. Which of the following risk factors should the nurse assess for this client?
asthma
A nurse is working with a client who has an impaired ability to smell...
Cranial nerve 1 (olfactory)
In examining a clients mouth with a penlight, the nurse notices salivary ducts that are visible on the buccal mucosa across from the second upper molars. The nurse recognizes these as which of the following?
Stenson's Ducts
A client presents to the health care clinic complaining of a sore throat. In examining the clients mouth and throat, the nurse notices the tonsils on both sides of the oropharynx at the end of the soft palate are swollen. Which tonsils are these ?
Palatine
A nurse is examining a client who is complaining of sinus pressure in his face and congestion. The nurse discovers tenderness on palpation of the sinuses and a large amount of exudate. Over which sinuses should the nurse expect to feel crepitus in this client?
Maxillary
A nurse is interviewing a client whose chief complaint is temporomandibular joint pain. Which of the following questions should the nurse ask regarding a causative factor?
Do you grind your teeth?
A nurse is assessing the mouth of an older client. Which of the following findings is common among older adults?
Receding and ischemic gums
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