Med Surg 1 Chapter 29 – Flashcards
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What is the highest priority of care for a patient with head and neck cancer who underwent a total laryngectomy with neck dissection 24 hours ago?
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Maintaining airway and ventilation Airway maintenance and ventilation are the highest priority. The extent of the surgery will determine the specific risk for the patient. Monitoring urinary output is a regular aspect of postoperative care, but it is not the highest priority if the airway or ventilation has the potential to be compromised. The family does require emotional support; an important aspect of this is knowing that the team will provide for the safety of their loved one. Body image changes can be challenging to deal with and must be addressed early in the future, but without an adequate airway and ventilation, the patient will develop other severe complications.
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In which scenario is a patient likely to require emergency endotracheal intubation?
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Dyspnea and stridor have occurred with bilateral vocal cord paralysis Bilateral vocal cord paralysis will not allow airflow into the trachea; this leads to a respiratory emergency and may require intubation. When the patient is unable to close a vocal cord due to paralysis, the risk is for aspiration during eating and drinking. Immediate coughing upon swallowing liquids may indicate aspiration and require treatment, but not endotracheal intubation. Polyps on the vocal cord can become edematous and will then interfere with closure of the vocal cords; this would also contribute to the risk for aspiration.
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Which surgery of neck cancer leads to absence of a natural voice?
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Total laryngectomy Total laryngectomy results in the patient having no natural voice. In transoralcordectomy, the patient may have a natural or hoarse voice quality. In vertical laryngectomy, the resulting voice quality is hoarse. Also, after a supraglottic partial laryngectomy, the patient may have a natural or hoarse voice quality.
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A patient's mother asks what is the most important thing she will need to know to care for her son who is having an inner maxillary fixation (IMF) completed as an outpatient. What does the nurse tell her?
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"Make sure he always has wire cutters with him." It is extremely important that the patient always have wire cutters in the event of emesis, so the wires can be cut to prevent aspiration. Remind the patient to contact the surgeon as soon as possible if the wires have been cut, so that fixation can be re-established. Antiemetics like promethazine, ondansetron, and prochlorperazine are prescribed by a health care provider on an as-needed basis only for nausea. Good nutrition ensuring adequate protein intake for healing must be maintained. A specific dental liquid diet will be reviewed with the patient and significant others before surgery. Dental hygiene will be maintained with an irrigation device like a WaterPik or SoniCare, not with a brush.
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Which intervention will be most effective in preventing complications from xerostomia in a patient undergoing treatment for neck cancer?
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Providing fluoride treatment A patient with xerostomia is at increased risk of tooth decay. Fluoride is the most effective treatment to prevent tooth decay and decrease the spread of tooth decay. Analgesic drugs are painkillers, used to provide relief from pain, so they will not prevent tooth decay. Tooth extraction involves removal of an infected tooth to prevent the spread of infection, but tooth extraction has no role in preventing tooth decay. A root canal is provided to a patient after tooth decay, which involves replacement of infected pulp (soft center of the tooth) with artificial pulp that helps keep the tooth in place. It does not prevent tooth decay.
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Patients with which risk factor warrant close monitoring for and education about cancers of the nose and sinuses?
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Chronic exposure to dust from wood, leather, or flour Chronic exposure to dust from wood, leather, or flour is known to be a risk factor for cancers of the nose and sinuses; individuals routinely exposed to these materials in a dust form should be encouraged to wear an appropriate mask. A history of allergies and sinus infections does not increase the risk of nasal/sinus cancers. A history of needing to sleep with the head of the bed elevated should be explored further for cause but is not likely to be related. Although an individual with nasal/sinus cancer may experience respiratory symptoms, the presence of persistent nasal drainage is not a risk factor in and of itself.
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The nurse is caring for a patient who has unilateral vocal cord paralysis after an injury to the neck. Which has the highest priority when developing a discharge teaching plan for this patient?
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Teaching the patient to tuck the chin down and tilt the forehead forward while swallowing Patients with unilateral vocal cord paralysis have an increased risk for aspiration while swallowing so they should be taught how to minimize this. The other items may be included in a comprehensive teaching plan but are not critical.
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The nurse is assessing a patient's sleep patterns to determine the presence of sleep apnea. What is a specific question that the nurse asks to determine this?
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"Do you snore loudly or experience daytime sleepiness?" Snoring and daytime sleepiness are signs of sleep apnea and are appropriate questions to ask. Falling asleep easily is an effect of sleep apnea but can also indicate other sleep disorders. Dreaming and loss of muscle control are not indicators of sleep apnea.
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Which nursing assessment has the highest priority when caring for a patient with facial trauma?
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Oxygenation Facial trauma has the potential to interfere with breathing by occluding the upper airways. The nurse should monitor the patient's oxygenation closely. Assessing for infection, pain level, and self-image are important but are not critical.
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The nurse is providing preoperative teaching to a patient who is about to undergo a supraglottic partial laryngectomy. The patient asks the nurse whether his voice will be normal after surgery. How does the nurse respond?
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"You will be hoarse after surgery, but your voice may become normal. Patients who have a supraglottic partial laryngectomy may have a normal or a hoarse voice after recovery from surgery since the false cords are removed. Patients who have a total laryngectomy will not have a natural voice. Patients who have a laryngofissure will have a normal voice. Patients who have a hemilaryngectomy will have a hoarse voice.
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Which principle about anterior versus posterior nasal bleeding must the nurse consider the priority?
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Posterior bleeding is an emergency because it cannot be easily reached Posterior bleeding is not as readily seen or as easy to treat with the application of pressure or ice, thus posterior bleeds are more likely to require emergency treatment. Anterior bleeding is more easily seen and treated with pressure. Documentation is important with both types of bleeds; however, it is more difficult to assess the amount of bleeding with a posterior bleed, and blood is more likely to be swallowed. Various stimuli can trigger a nosebleed and sometimes no trigger can be identified.
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Which factor may contribute to sleep apnea?
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Obesity Excessive adipose tissue in the neck in obese patients can contribute to an increased risk of the tongue causing a partial obstruction as it falls back in the throat. While uncontrolled hypertension and sleep deprivation can be comorbidities in an individual with sleep apnea, as a separate problem they are not a major cause of sleep apnea. Modafinil may be prescribed for individuals with significant daytime sleepiness due to sleep apnea.
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The nurse is assessing a patient who underwent nasoseptoplasty 24 hours ago. Which finding requires immediate intervention by the nurse?
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Excessive swallowing Excessive swallowing in a patient who has undergone a nasoseptoplasty may indicate posterior nasal bleeding and requires immediate attention. Because of the very vascular nature of the face, ecchymosis is a normal finding in the patient who has undergone a nasoseptoplasty. Edema is a normal reaction to any kind of trauma, including that caused by surgery, so it is not an unexpected finding for this patient. A sore throat is a common side effect of endotracheal intubation.
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Which is considered the priority in treatment planning for patients with head and neck cancers?
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Normal lifestyle and functional ability must be preserved. Preservation of normal function without compromising long-term effectiveness of treatment is a priority in patients with head and neck cancers, especially to decrease problems with swallowing/aspiration and speech to maximize quality of life. The likelihood of a cure with radiation is dependent on the extent of the disease and sensitivity to the therapy. Chemotherapy may actually be used alone or in combination with radiation and even surgical therapy. Nonsurgical management is not limited to palliative expectations in tumors identified early in a curable stage.
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A patient has been diagnosed with nasal fracture. What measure does the nurse plan to initiate immediately upon admission to prevent complications?
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Assessment for an airway obstruction Prompt recognition of an airway obstruction provides the opportunity to remedy the problem early. Although the other answers all address potential problems in patients with upper respiratory disorders, the immediate need at time of admission is to confirm and maintain a patent airway.
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What is the priority of care for the nurse when working with patients who are experiencing disorders of the upper respiratory tract?
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Ensuring a patent airway to promote oxygenation
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What differentiates cerebrospinal fluid leakage from normal nasal secretions?
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Glucose Content Cerebrospinal fluid contains glucose and this can be tested using a dipstick test. In other nasal secretions, glucose is absent. Viscosity refers to the thickness of a fluid and both cerebrospinal fluid and nasal secretions are thin. Cerebrospinal fluid and nasal secretions will not contain lipid.
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The nurse manager at a long-term care facility is planning care for a patient who is receiving radiation therapy for laryngeal cancer. Which of these tasks will be best to delegate to a nursing assistant?
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Washing the skin with soap and water Personal hygiene is within the scope of practice of the nursing assistant. Throat-numbing lozenges should not be administered by nursing assistants because they are medication and administering medication is out of the scope of practice. Assessment is a complex task that must be completed by licensed nursing staff. Educating the patient is the responsibility of licensed nursing staff and is an ongoing part of the patient's care.
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A patient who has chronic exposure to textile dust is fearful about the risk for sinus cancer after a coworker developed the disease. To help assess risk, the nurse asks the patient about which other risk factor?
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Cigarette Smoking Patients who have exposure to common workplace substances have an increased risk of sinus cancer from these substances if they smoke. Alcohol intake, dietary fat, and exercise habits are all part of the usual health history, but they do not have a special concern for determining risk for sinus cancer.
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A patient has undergone nasal surgery. Which finding indicates a safety priority to the nurse?
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Frequent swallowing Frequent swallowing may indicate a posterior nasal bleed that will require intervention by the surgeon. Restlessness may be present, especially if the patient is in pain. Excessive sedation may be related to residual anesthesia effects or pain medications. Nausea and vomiting, while important to treat, are not the safety risk the posterior bleed would be. Good care involves all of these aspects; however, the initial focus should be on the potential presence of bleeding.
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Which nursing action has the highest priority when caring for a patient with laryngeal trauma?
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Maintaining a patent airway Maintaining a patent airway remains the nursing priority until the trauma to the larynx has healed. Pain and bleeding management and communication are secondary priorities to a patent airway.
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A patient has undergone neck dissection surgery and has a skin flap and a closed surgical drain. The nurse has been monitoring drainage hourly on the first postoperative day and notes a decrease in amount from 20-30 mL hourly to less than 5 mL in 1 hour. The nurse suspects which cause for this decrease in drainage?
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A clot obstructing the drain A sudden decrease in drainage from a wound drain can indicate a clot obstructing drainage from the wound site. Most drains are sutured in place and it is not likely the drain is dislodged. Edema is not a likely cause. Granulation tissue does not begin to form on the first postoperative day.
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A patient is being evaluated for laryngeal cancer. Besides tobacco use, which aspect of the patient's history is important for the nurse to assess?
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Alcohol consumption The two most important risk factors for head and neck cancer are tobacco and alcohol use, especially in combination. Dietary habits may need to be assessed in the chronic alcohol user as part of a comprehensive health evaluation, but do not necessarily contribute to development of cancer. Patients who have severe gastroesophageal reflux disease (GERD) have an increased risk for head and neck cancers. Shortness of breath may be a symptom in a patient with head and neck cancer.
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A patient who has undergone a partial laryngectomy for neck cancer has been a heavy smoker for many years and tells the nurse that it will be easy to avoid smoking now that this has occurred. How does the nurse respond?
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"Tell me about any times you have tried to quit smoking in the past." Studies are mixed when correlating confidence about attempts to quit smoking and successfully quitting smoking. An important initial assessment should be to identify how difficult the patient perceives smoking cessation to be. Asking the patient to describe previous attempts will help to determine this perceived difficulty. Getting patients to participate in a smoking cessation group will increase the chances of success; excessive confidence may be detrimental because smokers who are confident that they can quit are less likely to join a group. The nurse should not reinforce excessive confidence and should also not discourage the patient.
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The nurse is caring for an older adult with Alzheimer's disease. The nurse provides meticulous oral care to prevent which condition?
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Airway obstruction Patients who have an altered mental state are at risk for thickening and hardening of oral secretions, or inspissated secretions, that can block the airway and lead to death. Oral hygiene can prevent this. Inspissated secretions do not cause laryngeal edema, pharyngeal abscess, or pharyngitis.
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Which measure aids in reducing anxiety in a patient with head and neck cancer who is scheduled for surgery?
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Encouraging the patient and family to discuss their fears Patients with head and neck cancer and their families can be extremely anxious before surgery as they face multiple unknowns. Attentive listening to their concerns, whatever they may be, serves to reduce some of the anxiety they are experiencing. No one can provide definite answers to all of the uncertainties they face; however, addressing the ones that are overwhelming them at this time will aid their comprehension of teaching and improve their overall experience. Teaching will be an important component of care; however, they must be able to effectively receive the information provided. Anxiety interferes with receptiveness and learning of new information. Cure rates and treatment options are important to discuss if that is their major concern and should be addressed when indicated but not as an automatic response to apparent anxiety.
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What is the priority nursing action for patients who have experienced facial trauma?
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Airway assessment It can be difficult to determine the extent of trauma with a facial injury, so these patients should be monitored closely for adequacy of their airway. Obstruction related to the trauma can lead to further respiratory complications. Assessment of pulse oximetry, checking for bruising, and monitoring for pulse changes would also be part of the patient's care; however, the priority is to ascertain that the airway is patent.
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A patient who is receiving combination chemotherapy and radiation therapy for neck cancer reports increasingly uncomfortable oral cavity effects such as stomatitis and gingivitis. What does the nurse recommend for this patient?
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Providing oral care and comfort measures Stopping or taking a break from therapy is not recommended even when side effects become very uncomfortable. Patients should be taught prior to beginning therapy about ways to manage side effects.
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What are the symptoms of sleep apnea? Select all that apply.
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Snores heavily Waking up tired Daytime sleepiness Snoring, waking up tired, and sleepiness during the daytime are symptoms of sleep apnea. Sleep apnea causes upper airway obstruction, and is unassociated with neck and chest pain.
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What is the most suitable position in which the nurse should place the patient with epistaxis?
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Upright and leaning forward position Upright and leaning forward is the best position for a patient with epistaxis because it prevents blood from entering the airway. The prone position (lying face down) will increase nasal bleeding. A supine position (flat on the back) creates pressure on the head, which will cause bleeding. A semi-Fowler's position (sitting at 30°-45°) will not reduce bleeding.
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Which factor helps prevent wound breakdown?
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Intake of a protein-rich diet Intake of a protein-rich diet promotes wound healing. Wound breakdown is caused by poor nutrition, alcohol use, radiation therapy, and smoking.
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Which surgical procedure involves the removal of the entire larynx in patients with laryngeal cancer?
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Total laryngectomy Total laryngectomy involves complete removal of the larynx. Laser surgery destroys or reduces a tumor by a laser beam. In laryngofissure, no cord is removed since it treats an early lesion. In transoralcordectomy, a tumor is removed through laryngoscope.
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Which two factors in combination are the greatest risk factors for head and neck cancer?
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Alcohol and tobacco use The combination of alcohol and tobacco use is one of the greatest risk factors for head and neck cancer. Chronic laryngitis and voice abuse in combination are not the greatest risk factors; however, each one individually is a risk factor for head and neck cancer. No large, randomized, controlled studies have identified a relationship between marijuana use and head and neck cancer. Exposure to industrial chemicals may increase a person's risk. Poor oral hygiene is a risk factor, as is chewing tobacco; however, no studies have reported that a combination of the two will lead to increased risk. The same cancer-causing agents in smoking tobacco may be present in smokeless (chewing) tobacco.
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A patient admitted for sleep apnea asks the nurse, "Why does it seem like I wake up every 5 minutes?" What is the nurse's best response?
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"Because your body isn't getting rid of carbon dioxide. This is what stimulates your body to wake up and breathe." During sleep, the muscles relax and the tongue and neck structures are displaced with the tongue falling back, causing an upper airway obstruction. This obstruction leads to apnea and increased levels of carbon dioxide. Respiratory acidosis stimulates neural centers in the brain, and the patient awakens, takes a deep breath, and goes back to sleep. After the patient returns to sleep, the cycle may be repeated as often as every 5 minutes as the airway is reobstructed. Too much carbon dioxide, not a lack of oxygen, is the trigger that causes the patient to awaken and breathe. Technically the patient is not choking. Telling the patient he or she isn't really awakening that often minimizes the patient's concern and is not accurate. The patient may be awakening every 5 minutes as the cycle repeats.
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Which of the patient's actions during self-management after a laryngectomy can lead to complications?
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Swimming Swimming should be avoided after laryngectomy to prevent an infection pathway related to the stoma. Crusting around the stoma should be prevented with a saline solution rinse of the area. The stoma should be cleaned with mild soap and water to prevent infection. The stoma should be covered while coughing because the pressure can cause mucus secretions.
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What is the Epworth Sleepiness Scale (ESS) used to assess?
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Sleep Apnea The Epworth Sleepiness Scale (ESS) is used for the assessment of sleep apnea. The ESS scale is not used to assess patients who are having neck trauma, laryngeal trauma, or vocal cord paralysis. These conditions are not related to sleep disorders but are associated with disorders of the larynx.
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A patient who has fallen off a roof arrives in the emergency department with possible head, neck, and chest trauma. The health care provider orders the following treatments. Which action will the nurse take first?
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Immobilize the neck with a cervical collar. If the cervical spine has not already been stabilized by EMS (emergency medical services), this is the nurse's top priority. The neck should be held in place manually until a properly fitted cervical collar can be applied. Innervation of the diaphragm is between cervical spine levels 3 and 5. Oxygen administration is important; however, this is not the nurse's first priority and is considered separate from establishing an airway. Two large-bore (16- or 18-gauge IV catheter) IVs should be established and an isotonic fluid such as normal saline should be infused at a rate determined by the patient's condition and vital signs. CT scans are not the top priority and should be based on the patient's reported problems and condition.
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Which is an orbital-zygoma fracture?
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Le fort III A Le fort III is an orbital-zygoma fracture called a craniofacial disjunction. A Le fort II is a maxillary and nasoethmoid complex fracture. Nasal and maxillary fractures are simple fractures of the bones after which they are named.
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A patient with laryngeal cancer is admitted to the medical-surgical unit the morning before a scheduled total laryngectomy. Which preoperative intervention can be accomplished by an LPN/LVN working on the unit?
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Administering preoperative antibiotics and anxiolytics Administering medication is a skill within the LPN/LVN scope of practice. As a reminder, anxiolytics must be administered AFTER the operative consent has been signed, or the consent will be invalid. The patient's nutritional status and need for nutritional supplements should be assessed by the RN or a registered dietitian as part of the multidisciplinary care team. The surgeon is responsible for discussing the laryngectomy procedure, answering any questions, and having the patient sign the operative consent form. Patient teaching is the responsibility of the RN because it requires complex critical thinking skills.
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Which intervention does the nurse anticipate when a patient is experiencing airway obstruction due to the tongue falling back or excessive secretions?
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Slight extension of the head and neck Extending the patient's head and neck may actually be sufficient to alleviate the partial obstruction caused by the tongue falling back in the throat; this may especially help to align the neck to decrease the accumulation of any secretions in the throat. Placing the patient in prone position will make the situation worse. A nasogastric tube will not assist in removing secretions. The patient should first be repositioned, which may eliminate the need for intubation.
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A postoperative patient who was intubated has a breathy, weak, "wet"-sounding voice and coughing associated with swallowing. Which action by the nurse is correct?
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Place the patient in high-Fowler's position Securing an airway is the main intervention. Place the patient in a high-Fowler's position to aid in breathing and proper alignment of airway structures. Assess for airway obstruction. This patient shows signs of aspiration possibly due to vocal cord paralysis. Incentive spirometry is not indicated. If the patient is aspirating, no oral liquids or solids should be given. The Rapid Response Team should be notified if the patient develops dyspnea with stridor.
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The nurse is caring for a patient who is in fixed occlusion for a jaw fracture. The most important reason for the nurse to provide oral care with an electronic irrigation system (WaterPik) several times daily is to prevent which condition?
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Mandibular infection Treatment delay, poor oral care, and tooth infection may contribute to mandibular bone infection, which may require antibiotic therapy and sometimes surgical débridement of the infected bone. Oral care can help to prevent dental caries, gingivitis, and dry oral mucous membranes, but these do not prolong treatment for this patient.
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Which antianxiety drug has the shortest duration of action?
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Lorazepam Lorazepam is an antianxiety drug of short duration and has a low number of respiratory side effects. Diazepam is also an antianxiety drug, but it is not a short-duration drug and causes respiratory depression. Morphine and cevimeline are not antianxiety drugs. Morphine is used for pain management of neck and head cancers. Cevimeline is used for xerostomia; it acts as a saliva stimulant.
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The nurse is caring for a patient after extensive head and neck surgery and notes a small area of bright-red blood on the dressing, which is bigger 30 minutes later. Which nursing action is important to take?
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Notify the Rapid Response Team Patients who have undergone extensive head and neck surgery are at increased risk for carotid rupture, which can be life-threatening. The nurse should notify the Rapid Response Team. Reinforcing the dressing does not help stop bleeding. Applying pressure could rupture the artery. Pressure should be applied in the event of a rupture.
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Which statement about obstructive sleep apnea is correct?
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Increased carbon dioxide levels stimulate neural centers to awaken the sleeper. When apnea occurs, changes in blood gases awaken the sleeper who repositions to correct the obstruction and then returns to sleep. Patients are able to sleep but do not get restful or deep sleep. Recurrent sleep apnea does not cause irreversible brain changes. Untreated obstructive sleep apnea does not cause neurologic apnea.
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A patient calls the nurse to report a nosebleed that started with a sneeze. What does the nurse do first?
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Position the patient upright and leaning forward over an emesis basin Positioning the patient in an upright, forward-leaning position prevents possible aspiration of blood. The next action would be to apply pressure to the nose for 10 minutes. If that fails, packing is necessary. After the bleeding stops, the patient should receive instructions about ways to prevent a recurrence.
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A patient has received packing for a posterior nosebleed. In reviewing the patient's orders, which order does the nurse question?
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"Give ibuprofen 800 mg every 8 hours as needed for pain." Ibuprofen is contraindicated in a patient with a nosebleed because NSAIDs inhibit clotting. At least initially, bedrest is suggested because significant amounts of blood may have been lost owing to a posterior nosebleed; elevation of the head of the bed is recommended for patient comfort and to facilitate drainage of secretions. Humidified air and humidified oxygen, if oxygen is ordered, are recommended because dryness of the nasal mucosa is a cause of epistaxis (nosebleed). Any patient who is admitted for epistaxis needs suction at the bedside in the event of further bleeding.
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Which is not a cause of sleep apnea?
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Alcohol Alcohol does not contribute to sleep apnea. Obesity, which is a result of unhealthy lifestyle practices, contributes to sleep apnea. Smoking is another major factor that leads to sleep apnea. Anatomical abnormalities, such as a short neck, also contributes to sleep apnea.
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A patient who is about to undergo a supraglottic partial laryngectomy asks the nurse what the surgeon will remove during this procedure. The nurse explains to the patient that the surgeon will remove which structures?
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The hyoid bone, false cords, and the epiglottis A supraglottic partial laryngectomy involves removal of the hyoid bone, false cords, and the epiglottis. A hemilaryngectomy involves removal of one true cord, one false cord, and one-half of the thyroid. A total laryngectomy involves removal of the entire larynx. Laser surgery involves removal of the tumor only.
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A patient has been diagnosed with oral and laryngeal cancer. He completed a course of radiation, and it is 2 days since he underwent a total laryngectomy. The patient had been very anxious about his surgery. Which medications does the nurse expect to find on his home medication list?
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Lorazepam Lorazepam is a short-acting antianxiety medication that would be the most appropriate choice for this patient. Amitriptyline is a tricyclic antidepressant that would not be used specifically for this patient's anxiety. Although diazepam is an effective medication for anxiety, it is more likely to cause respiratory depression; the location of this tumor makes diazepam not the best choice for anxiety. Ketorolac is an NSAID and should not be used before surgery. Ketorolac should be used with caution, or not at all, if the patient is taking medication for anxiety.
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A patient is scheduled for surgical removal of a neck tumor followed by radiation treatments. The patient asks the nurse why radiation therapy is not performed prior to the surgery. How does the nurse respond?
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"Radiation therapy slows tissue healing." Radiation treatment slows tissue healing and is generally done after surgery. It is not withheld until after surgery because of tissue edema or changes in respiratory function. Radiation does not increase the risk of metastasis.
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Which interventions should the nurse include in the plan of care for a patient undergoing radiation therapy who develops a sore throat and difficulty swallowing? Select all that apply.
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Sucking on ice chips Gargling with saline water Using mouthwashes and throat sprays Sucking on ice chips will be beneficial to lessen sore throat pain. Gargling with saline water will help to soothe the throat and reduce difficulty in swallowing. Water and fluids should be increased, not decreased, to prevent a sore throat. Analgesic drugs are painkillers and should not be reduced. Mouthwashes and throat sprays have a local anesthetic agent that provides temporary relief from pain.
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A new patient arrives in the medical-surgical unit with a flap after a total laryngectomy. The flap appears dusky in color. What is the nurse's first action?
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Use a Doppler to assess flow to the area A complete assessment of the area including Doppler activity of major feeding vessels needs to be completed, and the surgeon must be notified because the patient may have to be returned to the operating room immediately. Neither hot nor cold packs (nor anything, for that matter) should be applied to the flap site. The site is delicate and should not be massaged.
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The nurse is planning care for the non-English-speaking patient who is on complete voice rest. What alternative method of communication does the nurse implement?
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Picture Board A picture board overcomes language barriers and can be used to communicate with patients who do not speak English well if a translator or a translation phone is not readily available. An alphabet board may or may not be useful if the patient does not speak English; this is not the best answer, but may be an option depending on what is available at the facility. A translator at the bedside would be beneficial for the nurse to speak with the patient, but not for the patient to ask questions or communicate concerns to the nurse. Unless the nurse is able to read the language the patient speaks, a word board would not be beneficial.
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The nurse is assessing a patient with facial trauma and observes clear drainage from the patient's left nostril. What is the nurse's next action?
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Test the drainage for glucose Drainage from the nares that is positive for glucose would indicate that it is cerebrospinal fluid leaking from a skull fracture. This should be determined before calling the provider. Suctioning the nares in the presence of a possible skull fracture is contraindicated, as it may introduce bacteria through the opening. Packing may or may not be ordered by the provider, but it is not the nurse's next action.
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A patient diagnosed with mild obstructive sleep apnea asks the nurse if surgery will be necessary. What does the nurse tell this patient?
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"Mild symptoms can be treated by changing sleeping positions or by losing weight." Mild symptoms can be treated with conservative measures such as repositioning or weight loss. More severe apnea will require noninvasive positive pressure and then surgery if that is not effective. Medications treat daytime sleepiness that results from chronic sleep apnea but does not treat the cause.
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A patient with sleep apnea who has a new order for continuous positive airway pressure (CPAP) with a facemask returns to the outpatient clinic after 2 weeks with a report of ongoing daytime sleepiness. Which action should the nurse take first?
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Ask the patient whether CPAP has been used consistently at night The nurse should assess whether the patient has actually consistently been using CPAP at night because patients may have difficulty with the initial adjustment to this therapy. With APAP, the pressures are adjusted continuously depending on the patient's needs; this may be more comfortable for the patient. Modafinil treats narcolepsy or daytime sleepiness; it does not treat the cause of sleep apnea, but it may be used to help some of the side effects of obstructive sleep apnea. A nasal mask may be an option for the patient if he or she is finding the facemask used with CPAP uncomfortable.
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A patient presents to the emergency department with facial trauma after a motor vehicle accident. The nurse notes extensive bruising behind the ears and suspects which of the following conditions?
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Skull fracture and brain trauma Extensive bruising in the mastoid area is associated with skull fracture and brain trauma. Lower jaw fractures and spinal fractures are not associated with extensive bruising behind the ear. Soft tissue injury may cause bruising, but this finding is related to more severe injury.
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When caring for a patient with head and neck cancer following a total laryngectomy 12 hours ago, which potential complications are important for the nurse to address? Select all that apply.
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Airway obstruction and inadequate oxygenation Comfort and nonverbal communication Wound breakdown and hemorrhage Significant potential complications after surgery for head and neck cancer include wound breakdown, airway obstruction/compromise, pain management, and adequate nonverbal communication. This is an extremely stressful time for patients and their families; attentiveness to these aspects of the recovery process can prevent complications and delayed recovery. Once the patient is past the early postoperative period, preparation for teaching about radiation therapy will be needed if it is a recommended treatment. The nurse will not teach a patient about chemotherapy unless this is the prescribed course of treatment. It is also not a priority during the early postoperative period.
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The standard laryngectomy plan of care for a patient admitted with laryngeal cancer includes these interventions. Which intervention will be most important for the nurse to accomplish before the surgery?
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Establish a means for communicating during the immediate postoperative period, such as a Magic Slate or an alphabet board. In the immediate postoperative period, relieving pain and anxiety is going to be a major priority. Because the patient will be unable to communicate verbally, establishing a way to communicate before the surgery will help by having a plan in place. Aspiration is not a risk after a total laryngectomy because no connection is present between the mouth and the respiratory system. It will be several weeks before the patient will need to address appropriate clothing; overloading the patient with too much information before surgery is unnecessary. Suctioning and wound care is discharge teaching that can be started after the surgery when the patient and significant others are more likely to retain the information owing to decreased preoperative anxiety. The significant others can observe the care and then can begin to take over more of the care while the patient is still in the hospital in a supervised environment.
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The abdominal thrust maneuver (formerly known as the Heimlich maneuver) for acute airway obstruction attempts to achieve which outcome?
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Expel the air remaining in the victim's lungs The quick inward motion of the abdominal thrust maneuver expels the air remaining in the victim's lungs, and with it, the foreign body causing the obstruction.
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The nurse assesses that an unconscious patient is struggling to breathe. What is the nurse's first action?
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Extend the patient's head and neck. Patients who are unconscious often have airway obstruction caused by the tongue falling back or by excessive secretions. The initial step is to extend the head and neck. Inserting an oral or nasal airway device and suctioning may be done next. Once the airway is established, oxygen may be necessary.
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The nurse is caring for a patient who has undergone a hemilaryngectomy for laryngeal cancer. Once a feeding tube has been placed and the patient's intestinal tract has recovered from the effects of anesthesia, which action by the nurse is appropriate for the next few days?
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Ensuring an individualized nutrition plan is followed for calorie needs Once a feeding tube is placed, it is important for patients to receive adequate calories to promote tissue healing; a diet that provides 35-40 kcal/kg/day is recommended. Protein and fluids are also important, but a high-carbohydrate diet is not indicated. It is important to establish nutrition with adequate calories and protein, so a clear liquid diet will not be sufficient. The feeding tube should be maintained with tube feedings for 7-10 days and then removed once the patient can swallow; patients will not aspirate since the airway and the esophagus have been separated.
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What will be the drug of choice for a patient whose cancer overexpresses the epidermal growth factor receptor?
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Cetuximab Cetuximab is prescribed to patients whose cancer overexpresses the epidermal growth factor receptor. It blocks epidermal growth factor receptors in the tumors and normal tissues. Salagen is used in xerostomia because it acts as a saliva stimulant. Salivart is also prescribed in xerostomia because it acts as artificial saliva. Cisplatin is chemotherapy used to destroy cancer cells.
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A patient comes to the emergency department (ED) with a bruised and swollen nose after being hit with a baseball 2 days ago. X-ray reveals a displaced fracture of the nose. Which order does the nurse anticipate implementing?
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Applying a cool compress and administering analgesic medication A patient who has a displaced nasal fracture will require a closed reduction, which should be performed within 24 hours after the injury. After 24 hours, the fracture is difficult to reduce because of edema and scar formation, so the provider will wait up to several days until the swelling is gone to reduce the fracture. The nurse should expect to provide care that limits pain and swelling, which includes cold compresses and analgesics. Packing the nose is not necessary unless there is uncontrolled bleeding. A rhinoplasty is done for complex fractures or those that don't heal properly.
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Which outcome indicates effectiveness modafinil administered to a patient with sleep apnea?
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Increased daytime wakefulness The drug modafinil promotes daytime wakefulness in patients with sleep apnea. Hypertension is a long-term effect of untreated sleep apnea. Untreated sleep apnea results in loss of deep sleep at night. Having increased feelings of exhaustion after waking is a symptom of untreated sleep apnea.
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Which factor is least likely to be considered while assessing a patient's nutritional status?
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Unusual bleeding Unusual bleeding is not a factor related to nutrition. Hair quality is decreased due to poor nutritional status. Generalized edema may occur due to inadequate nutritional intake. Decreased muscle mass decrease can be due to poor nutrition.
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Which clinical manifestation in the patient with facial trauma is the nurse's first priority?
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Stridor Sounds like whale crying..is an indication of a partial airway obstruction and requires immediate attention. Although bleeding is important in all trauma patients, it is not the first priority in assessing the ABCs. The question does not specify where the bleeding is occurring. The type (venous or arterial) and quantity of the bleeding need to be noted. Visual acuity will be assessed in the secondary survey because it is not considered life-threatening. Pain must be addressed to fully evaluate a patient and complete a reliable examination; however, it is not the nurse's first priority.
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A patient has sustained a traumatic brain injury and is mechanically ventilated. Which statement indicates a safety issue and should be addressed by the nurse?
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Poor oral hygiene can lead to respiratory crisis from secretions Many patients with traumatic brain injury (TBI) cannot perform their oral care unassisted and will potentially experience buildup of secretions and drying of the mucous membranes if they are mouth-breathing. Large amounts of accumulated and dried secretions can actually contribute to airway obstruction. Vocal cord damage is not usually directly associated with TBI. Tracheotomy is not always needed with TBI. Although a cough reflex is important to protect the patient's airway, it does not negate the need for good oral hygiene.
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Which statement made by the patient indicates a need for further teaching about how to manage a breathing stoma?
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"I will limit the amount of water I drink to keep the stoma dry." The patient with a stoma should stay hydrated to prevent secretions from thickening. The patient should increase the humidity in his or her home to keep the stoma moist. Using a shower shield on the stoma while bathing prevents entry of water into the airway. The stoma should be covered while shaving with an electric razor to prevent hair from entering the airway.
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A patient has a stoma after undergoing a laryngectomy, and the nurse is preparing the patient for discharge. Which statement by the patient indicates that more teaching is needed?
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"I should not cover the stoma while coughing or sneezing." Patients who have undergone a laryngectomy should be taught to cover the stoma when coughing or sneezing. They should also cover the stoma while shaving to prevent hair from getting inside. The stoma should be cleaned with soap and water. Patients should take appropriate precautions when around water and should not swim.
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Which surgical procedure is performed if a patient's lymph nodes, sternocleidomastoid muscle, jugular vein, and 11th cranial nerve have to be removed?
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Neck dissection Neck dissection includes removal of the lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve, and surrounding soft tissues. Tracheostomy helps to safeguard the airway. Total laryngectomy separates the upper airway from the throat and esophagus, and a permanent laryngectomy stoma is created. In partial laryngectomy, a part of the larynx or voice box is removed.
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A patient who has had a recent laryngectomy continues to report pain. Which medication would be best used as an adjunct to a narcotic once the patient can take oral nutrition?
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Liquid NSAIDs NSAIDs are an excellent adjunct when used with narcotics or opioid analgesia. Steroids will not help in pain relief and will delay healing. An opioid antagonist will reverse the effect of the narcotic. Diazepam has no pain-relieving properties.
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A patient who has received radiation therapy for laryngeal cancer 2 weeks prior asks the nurse when the hoarseness will improve. Which answer by the nurse is correct?
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"You will need to continue voice rest for 2-4 more weeks. Radiation therapy may cause worsening of hoarseness, and this may persist for 4-6 weeks. Patients will need to maintain strict voice rest until this symptom clears. Gargling with mouthwash is recommended to treat the discomfort caused by tissue dryness. Persistent hoarseness within 4-6 weeks of radiation therapy does not indicate the spread of cancer. Radiation therapy causes some permanent changes to tissues but not hoarseness.
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A patient is diagnosed with a head and neck lesion that is highly suspicious of cancer. In what way does the nurse demonstrate psychosocial support for the patient and family?
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Listens closely to their concerns regarding quality of life after treatment This situation requires attentive listening to the concerns of the family. Based on their history and knowledge of head and neck cancer, their specific needs will vary, but the important thing is to listen and address their concerns. While the other answers are all potentially part of the overall process, their initial anxiety will limit their ability to receive other meaningful information. The prognosis and treatment recommendations will be based on the extent and type of tumor (if malignant). The focus should be on what is causing them concern and presenting honest information from a caring perspective.
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Which intervention made by the student nurse may complicate the condition of a patient with an obstructed airway and weak voice?
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Place the patient in an upright and leaning forward position. An obstructed airway and weak voice are symptoms of vocal cord paralysis. Placing the patient in an upright and leaning forward position will create pressure on the head, thus aggravating the breathing difficulty. The patient should always be placed in a high-Fowler's position, which will help in easy breathing. Securing the airway is the most important step because it helps in regaining breathing. Assessing for an airway obstruction is essential to know the reason for the blockage in the airway. Proper alignment of the airway helps the air to reach the lungs.
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Xerostomia is a condition associated with which of the following types of treatment?
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Radiation therapy Xerostomia is dryness of the mouth which occurs with radiation therapy. It occurs when the salivary glands are in the irradiation path. The side effect is long-term and may be permanent.
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A postoperative patient develops stridor and becomes short of breath immediately following a thyroidectomy. What action does the nurse take?
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Notify the rapid response team Vocal cord paralysis can occur following a thyroidectomy, and the combination of stridor and dyspnea is an emergency requiring endotracheal intubation or tracheostomy. A chest x-ray may be performed if aspiration is suspected after the patient is stabilized. Teaching the patient to hold the breath while swallowing is appropriate for a patient with vocal cord paralysis who is stable.
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Which teaching by the student nurse to a patient who underwent a rhinoplasty may result in complications during the postoperative period?
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"Apply a hot water bottle to the nose." Following rhinoplasty, a hot water bottle may increase the risk of bleeding due to tissue friability. Therefore, the student nurse should instruct the patient to use cool compresses, which helps to reduce swelling and bruising. The patient should rest in a semi-Fowler's position (30°-45°), which reduces pressure on the surgical area. Soft foods should be eaten to reduce pressure on the nearby tissues. Drinking lots of water will keep the patient well-hydrated.
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Which statement by a patient with a laryngectomy indicates a need for further discharge teaching?
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"I can't put anything over my stoma to cover it. Loose clothing or a covering such as a scarf can be used to cover the stoma if the patient desires. To avoid aspiration, the patient with a laryngectomy should not swim. Mild soap and water is the proper way to clean the stoma; however, a shield should be used in the shower so a large amount of water does not enter it. The patient may project mucus when he laughs or coughs; reinforce with the patient and the family that this is normal and is to be expected.
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The RN is observing a new nurse providing care for a patient admitted with anterior epistaxis (nosebleed). What actions taken by the new nurse are appropriate for this patient? Select all that apply.
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Apply direct lateral pressure to the nose for 10 minutes. Maintain Universal Body Substances Precautions. Apply ice or cool compresses to the nose. Instruct the patient not to blow the nose for 24 hours The correct position for a patient with an anterior nosebleed is upright and leaning forward to prevent blood from entering the stomach and to avoid aspiration. The nurse should instruct the patient to apply pressure for 10 minutes by pinching the nares. Standard Precautions should be utilized because bodily fluid is present. Ice or cool compresses will help stop the bleeding. The patient should not attempt to blow the nose for 24 hours because the newly formed clot can become dislodged.
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The nurse is teaching a patient who underwent surgery for mandibular fracture with inner maxillary fixation about self-care upon discharge. Which statement regarding self-management made by the patient indicates effective learning?
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"I will cut the wires if I vomit." With inner maxillary fixation, bones are realigned and then wired in place with the closed bite. If the patient vomits after an inner maxillary fixation, the patient should immediately cut the wires to prevent aspiration. Irrigating devices are important for maintaining oral health because a patient cannot brush after surgery until completely healed. The patient should consume only a liquid diet, because chewing is not possible after surgery. Rewiring should be done only by the licensed practitioner.
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Which diagnostic study is used to differentiate normal tissue from a diseased one?
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Magnetic resonance imaging (MRI) MRI is used to differentiate normal tissue from diseased tissue. Computed tomography helps to analyze a tumor's exact location. Positron emission tomography and single-photon emission computerized tomography help to locate additional tumor sites.
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Which procedure involves removal of the hyoid bone?
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Supraglottic partial laryngectomy Supraglottic partial laryngectomy involves removal of the hyoid bone. Laser surgery, transoral cordectomy, and vertical laryngectomy are not associated with the removal of the hyoid bone. Laser surgery reduces the tumor or destroys a tumor completely through laryngoscope. Transoral cordectomy involves cutting off a tumor through laryngoscope. Vertical laryngectomy involves removal of one true cord, one false cord, and one-half of the thyroid cartilage.
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What clinical manifestation related to respiratory difficulty does the nurse expect to observe in a patient who has experienced laryngeal trauma?
answer
Nasal flaring Laryngeal trauma is likely to cause obstruction of the trachea. Nasal flaring is a manifestation of the body's attempt to compensate and bring in more oxygen. If the patient cannot compensate and bring in adequate oxygen, the saturation level will gradually decrease. The CO2level will most likely increase. Humidification may be indicated for long-term use, especially for high-flow oxygen, but poor response to humidification is not a manifestation of respiratory difficulty. Increased nasopharyngeal secretions would not necessarily be present as a result of laryngeal trauma.
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The nurse is caring for a patient who underwent tracheostomy. Which nursing intervention is likely to cause aspiration?
answer
Eating watermelon Watermelon should be avoided because thin liquids cause difficulty in swallowing and aspiration. Thickened liquids should be given to the patient because they do not have a risk of aspiration. The patient should be given smaller and more frequent meals, which will reduce the risk of aspiration. The patient should be placed in an upright position to avoid aspiration.
