Page 375 - Saunders Comprehensive Review For NCLEX-RN

b. Instruct the client in the proper method
of cleaning the ear canal.
c. The client should cleanse the ear canal
with the corner of a moistened
washcloth and should never insert
sharp objects or cotton-tipped
applicators into the ear canal.
E. Nose, mouth, and throat: Includes inspection and palpation

1. Subjective data

a. Nose: Ask about discharge or nosebleed
(epistaxis), facial or sinus pain, history
of frequent colds, altered sense of
smell, allergies, medications being
taken, history of nose trauma, or
surgery.
b. Mouth and throat: Ask about the
presence of sores or lesions; bleeding
from the gums or elsewhere; altered
sense of taste; toothaches; use of
dentures or other appliances; tooth and
mouth care hygiene habits; at-risk
behaviors (e.g., smoking, alcohol
consumption); and history of infection,
trauma, or surgery.

2. Objective data

a. External nose should be midline and in
proportion to other facial features.
b. Patency of the nostrils can be tested by
pushing each nasal cavity closed and
asking the client to sniff inward
through the other nostril.
c. A nasal speculum and penlight or a
short, wide-tipped speculum attached
to an otoscope head is used to inspect
for redness, swelling, discharge,
bleeding, or foreign bodies; the nasal
septum is assessed for deviation.
d. The nurse presses the frontal sinuses
(located below the eyebrows) and over
the maxillary sinuses (located below
the cheekbones); the client should feel
firm pressure but no pain.
e. The external and inner surfaces of the
lips are assessed for color, moisture,
cracking, or lesions.

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