Assessment: Mouth, Throat, Nose, and Sinuses

Which technique should the nurse use to examine the sinuses of a client with a sinus infection?

• Insert a penlight into the oral cavity and angle it toward the roof of the mouth.

• Press up on the brow on each side of the nose to palpate the frontal sinus.

• Inspect the frontal and maxillary sinuses with an otoscope.

• Indirectly percuss over the cheekbones for dullness or pain.

An elderly client diagnosed with sinusitis undergoes a transillumination test to detect the presence of fluid or pus in the maxillary sinus. Which precaution should the nurse take to avoid an inaccurate result?

• Instruct the client to remove upper dentures.

• Hold the light source below the eyebrow.

• Dim the lights in the room during examination.

• Lightly tap with fingers over the maxillary sinus.

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?

• Pale, pink, swollen, with watery exudate.

• Dark pink, moist, & free of discharge.

• Bluish gray, swollen, with watery exudate.

• Red, swollen, with purulent discharge.

which action by a nurse is appropriate to prevent the gag reflex during observation of the uvula?

• Tell the client to open the mouth wide.

• Depress the tongue slightly off center.

• Press firmly on the back of the tongue.

• Ask the client to say "aaah".

During an examination of the oral cavity, which technique by the nurse is appropriate to examine the tongue?

• Use a square gauze pad to hold the client's tongue to each side.

• Ask the client to stick the tongue out between the lips.

• Use a penlight and tongue depressor to retract the lips.

• Put on gloves and retract the client's lips and cheeks.

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 the uvula. Using a grading scale of 1+ to 4+, how should the nurse appropriately document the tonsils?

• 4+

• 1+

• 2+

• 3+

Which assessment of the tongue should a nurse recognize as abnormal?

• Ventral surface with visible veins

• Fissured, topographical pattern

• Pale pink and moist

• Red with loss of papillae

A client presents to the health care clinic with reports of inability to concentrate at work and daily frontal headaches for the past two weeks. What additional information should the nurse ask this client:

• "Are you taking high blood pressure medication?"

• "Are you experiencing sinus pressure and congestion?"

• "Do you have a family history of severe headaches?"

• "Have you ever had an injury to your head or neck?"