Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

A painful ulcerated mucosal area inside the cheek for 1 day.

Stippled gingival margins that adhere firmly to the teeth.

A number of small yellowish-white and raised lesions on the buccal mucosa.

An ulceration under the tongue that has been present for the last three

Answer and Explanation

The Correct Answer is D

A.   A painful ulcerated mucosal area inside the cheek that has been present for only 1 day is concerning but less alarming in the short term compared to chronic lesions. Acute ulcers can be caused by minor trauma, infections, or canker sores. While it is important to monitor and evaluate these lesions, especially if they persist or worsen, a duration of only 1 day typically suggests it might be related to a transient condition.
B.   Stippled gingival margins that adhere firmly to the teeth can indicate gingival hyperplasia or certain systemic conditions like vitamin deficiencies. While this finding can be concerning and warrants further investigation into oral health or potential systemic issues, it is generally less urgent compared to other findings that may indicate malignancy or severe chronic conditions.

C.   Small yellowish-white lesions on the buccal mucosa could be oral leukoplakia or aphthous ulcers, which can be benign or related to underlying conditions. While these lesions need to be assessed to determine their cause, they are usually less immediately concerning than persistent ulcers that could indicate more serious issues.
D.   An ulceration under the tongue that has been present for three weeks is the most concerning finding. Chronic oral ulcers, especially those persisting for more than two weeks, can be indicative of serious conditions such as oral cancer or other malignancies. Persistent lesions warrant thorough investigation to rule out or address potential malignancy or other significant pathologies.

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Correct Answer is B

Explanation

A. This maneuver assesses shoulder strength and endurance but is not a direct measure of the normal range of motion. The test involves resistance but does not provide information on the full range of shoulder movement. It might reveal issues with muscle strength or endurance but does not effectively assess ROM.
B. This assessment technique evaluates shoulder flexion, where the client raises their arms straight up beside the ears, which is a key movement to measure in shoulder ROM. It assesses the ability to lift the arms fully overhead, which is an essential component of shoulder range of motion. This technique directly tests the normal ROM for shoulder flexion and abduction.
C. This maneuver tests coordination and proprioception rather than the range of motion. It is a test for the accuracy of movements and neurological function, particularly useful in assessing cerebellar function, but does not directly measure shoulder ROM.
D. This test assesses shoulder strength and stability rather than range of motion. It is useful for evaluating how well the shoulder can maintain a position but does not provide specific information about the range of motion in different directions.

A. Observe chest and upper neck for a rash. B. Evaluate for a loss of peripheral vision. C. Assess deep tendon reflexes. D. Perform a hearing test.

Correct Answer is D

Explanation

A. Observing the chest and upper neck for a rash is not directly relevant to assessing tinnitus. Tinnitus is an auditory condition, and a rash in these areas would not typically provide information about the presence or effects of tinnitus. This option is not suitable for evaluating tinnitus.
B. Evaluating for a loss of peripheral vision is related to visual assessments rather than auditory conditions. Peripheral vision loss does not provide direct information about tinnitus or its effects. This option is not relevant to assessing the impact of tinnitus.
C. Assessing deep tendon reflexes is a neurological examination that helps evaluate the functioning of the nervous system but does not provide information about tinnitus. Tinnitus is related to auditory perception and not directly assessed through reflexes.
D. Performing a hearing test is directly relevant to evaluating tinnitus. Tinnitus often accompanies hearing loss or auditory dysfunction. A hearing test can help determine if there is a hearing impairment or other auditory issues associated with tinnitus.

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Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client comes to the clinic due to shoulder discomfort and intermittent pain while swimming laps. To identify normal range of motion (ROM) of the client's shoulder, which assessment technique should the nurse ask the client to perform?

Correct Answer is B

Explanation

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is D

Explanation

A client reports to the healthcare provider's office for a routine post-surgical evaluation six weeks after a hysterectomy. Which history-taking approach should the nurse use to gather the needed information?

Which finding should raise the greatest concern for a nurse who is performing an ear nose and throat (ENT) examination?

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

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