chapter 53 - Chapter 53: Nose, Sinus, and Throat Disorders...

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Chapter 53: Nose, Sinus, and Throat Disorders MULTIPLE CHOICE 1. The nurse uses a picture to show the structures of the internal nose, which are the: 1. turbinates, sinuses, and eustachian tubes. 2. olfactory cells, mucous membrane, and vestibule. 3. vestibular formations, nasal hairs, and turbinates. 4. septum, sinuses, and turbines. ANS: 2 Olfactory cells, mucous membranes, and the nasal vestibule are all portions of the internal nose. PTS: 1 DIF: Cognitive Level: Knowledge REF: 1209 OBJ: 4 TOP: Anatomy and Physiology of the Nose, Sinuses, and Throat KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 2. The nurse explains to the parents of a toddler that the function of the tonsils and adenoids in small children is to: 1. help promote antibody formation. 2. assist in some digestive processes. 3. protect against bacterial infections of the throat. 4. support blood cell production. ANS: 3 The tonsils and adenoids consist of lymphatic tissue that acts as a bacterial barrier for the respiratory and gastrointestinal tract. PTS: 1 DIF: Cognitive Level: Knowledge REF: 1210 OBJ: 4 TOP: Anatomy of the Nose, Sinuses, and Throat KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity 3. A patient comes into the clinic complaining of a runny nose and facial pain. The nurse’s ini- tial assessment would include: 1. assessment for nasal drainage and sinus tenderness. 2. transillumination and nasal speculum examination. 3. palpation of the frontal and maxillary sinuses and tonsillar inspection. 4. turbinate assessment and assessment for patency of the nares.
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ANS: 1 The assessment of the characteristics of the nasal drainage and location of the facial pain would be the first evaluation for sinusitis. PTS: 1 DIF: Cognitive Level: Application REF: 1211 OBJ: 2 TOP: Physical Examination of the Nose KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 4. A 68-year-old patient tells the nurse that she can’t smell as well as before, feels like her nose is drier, and occasionally gets a nosebleed. The nurse explains that: 1. she may have an infection. 2. she has normal age-related changes. 3. she may have a nasal defect. 4. her allergies are causing her symptoms and she should use an over-the-counter de- congestant. ANS: 2 These are descriptions of normal age-related changes. A suggestion that would make the pa- tient more comfortable would be to use a humidifier to keep the mucous membranes moist. PTS: 1 DIF: Cognitive Level: Analysis REF: 1212 OBJ: 2 TOP: Age-Related Changes in the Nose and Sinuses KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity 5. The nurse is aware that the age-related relaxation of the esophageal sphincter in the 70-year- old patient will cause: 1. excessive belching. 2.
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chapter 53 - Chapter 53: Nose, Sinus, and Throat Disorders...

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