A patient comes into the clinic complaining of facial pain, fever, and malaise.

NURS330 Individual Assessment

Chapter 17 Quiz

Question 1A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate?

 

  Nasal polyps

 

  Frontal sinusitis

 

  Posterior epistaxis

 

  Maxillary sinusitis

 

 Question 2In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings?

 

  Refer the patient to a throat specialist.

 

  No response is needed; this appearance is normal for the tonsils.

 

  Continue with the assessment, looking for any other abnormal findings.

 

  Obtain a throat culture on the patient for possible streptococcal (strep) infection.

 

 Question 3When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause?

 

  Nasal polyps

 

  Acute rhinitis

 

  Acute sinusitis

 

  Allergic rhinitis

 

 Question 4When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process?

 

  Teeth appearing shorter

 

  Tongue that looks smoother in appearance

 

  Buccal mucosa that is beefy red in appearance

 

  Small, painless lump on the dorsum of the tongue

 

Question 5When assessing the tongue of an adult, what finding would be considered abnormal?

 

  Smooth glossy dorsal surface

 

  Thin white coating over the tongue

 

  Raised papillae on the dorsal surface

 

  Visible venous patterns on the ventral surface

 

Question 6A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother?

 

  “This area of irritation is caused from teething and is nothing to worry about.”

 

  “This finding is abnormal and should be evaluated by another health care provider.”

 

  “This area of irritation is the result of chronic drooling and should resolve within the next month or two.”

 

  “This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal.”

 

Question 7The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant?

 

  Sphenoid sinuses are full size at birth.

 

  Maxillary sinuses reach full size after puberty.

 

  Frontal sinuses are fairly well developed at birth.

 

  Maxillary and ethmoid sinuses are the only sinuses present at birth.

 

Question 8During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding?

 

  Check the patient’s Hb for anemia.

 

  Assess for other signs of insufficient oxygen supply.

 

  Proceed with the assessment, this appearance is a normal finding.

 

  Ask if he has been exposed to an excessive amount of carbon monoxide.

 

Question 9While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, “It makes a great pacifier.” What is the best response by the nurse?

 

  “You’re right. Bottles make very good pacifiers.”

 

  “Using a bottle as a pacifier is better for the teeth than thumb-sucking.”

 

  “It’s okay to use a bottle as long as it contains milk and not juice.”

 

  “Prolonged use of a bottle can increase the risk for tooth decay and ear infections.”

 

Question 10A 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?

 

  Inappropriate use of nasal sprays

 

  A problem with the patient’s coagulation system

 

  Increased susceptibility to colds and nasal irritation

  Increased vascularity in the upper respiratory tract as a result of the pregnancy

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