Chapter 22: Management of Patients With Upper Respiratory Tract Disorders – Flashcards
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A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first a) Makes a fist with one hand with the thumb outside the fist b) Exerts pressure against the worker's abdomen c) Stands behind the worker, who has hands across the neck d) Places both arms around the worker's waist
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c) Stands behind the worker, who has hands across the neck Explanation: The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking. pg. 538
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Late complications of radiation therapy may include which of the following? Select all that apply. a) Edema b) Xerostomia c) Loss of taste d) Fibrosis e) Laryngeal necrosis
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e) Laryngeal necrosis a) Edema d) Fibrosis Explanation: Complications occurring late may include laryngeal necrosis, edema, and fibrosis. Loss of taste and xerostomia are symptoms of radiation therapy that may occur earlier in treatment. pg.560
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The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following? a) Levofloxacin (Levaquin) b) Amoxicillin (Augmentin) c) Keflex (Cephalexin) d) Ceftin (Cefuroxime)
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b) Amoxicillin (Augmentin) Explanation: Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones, such as levofloxacin (Levaquin) or moxifloxacin (Avelox), can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin (Keflex) and cefuroxime (Ceftin), are no longer recommended as they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS. pg.543
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A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: a) "I should sleep on my side all night long." b) "I need to keep my inhaler at the bedside." c) "I should eat a high-protein diet." d) "I should become involved in a weight loss program."
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d) "I should become involved in a weight loss program." Explanation: Obesity and decreased pharyngeal muscle tone commonly contribute to sleep apnea; the client may need to become involved in a weight loss program. Using an inhaler won't alleviate sleep apnea, and the physician probably wouldn't order an inhaler unless the client had other respiratory complications. A high-protein diet and sleeping on the side aren't treatment factors associated with sleep apnea. pg.553
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The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? a) "I have environmental allergies." b) "I used my voice in excess over the weekend." c) "I smoke a pack of cigarettes a day." d) "I was chewing ice chips all day long."
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d) "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. pg.551
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After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? a) Throat pain b) Difficulty talking c) Bleeding d) Difficulty swallowing
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c) Bleeding Explanation: The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop. pg.549
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A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: a) Myalgias b) Headache c) Nausea d) Fever
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d) Fever Explanation: The signs and symptoms described are consistent with acute pharynigitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided. pg.547
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Which assessment finding puts a client at increased risk for epistaxis? a) Cocaine use b) History of nasal surgery c) Use of a humidifier at night d) Hypotension
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a) Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis. pg.555
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A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following? a) Hemilaryngectomy b) Partial laryngectomy c) Total laryngectomy d) Supraglottic laryngectomy
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b) Partial laryngectomy Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea. pg.559
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A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give? a) "You should rest, increase your fluids, and take Ibuprofen." b) "Antibiotics will be prescribed, which will make you feel better." c) "Have you tried a topic nasal decongestant; they work well." d) "Your symptoms should go away soon, just try to get some rest."
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a) "You should rest, increase your fluids, and take Ibuprofen." Explanation: Management of viral rhinitis consists of symptomatic therapy that includes adequate fluid intake, rest, prevention of chilling, and use of expectorants as needed. Warm saltwater gargles soothe the sore throat, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, relieve aches and pains. Antibiotics are not prescribed because they do not affect the virus causing the patient's signs and symptoms. Topical nasal decongestants should be used with caution. The symptoms of viral rhinitis may last from 1 to 2 weeks. pg.540
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You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? a) Provide meticulous mouth care every 4 hours. b) Monitor for signs of dysphagia. c) Encourage deep breathing every 2 hours. d) Caution against frequent coughing.
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c) Encourage deep breathing every 2 hours. Explanation: The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake. pg.563
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A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question? a) "Have you strained your voice recently?" b) "Do you smoke cigarettes, cigars, or a pipe?" c) "Do you eat a lot of red meat?" d) "Do you eat spicy foods?"
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b) "Do you smoke cigarettes, cigars, or a pipe?" Explanation: Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness. pg.551
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What client would be most in need of an endotracheal tube? a) Comatose clients b) Ambulatory clients c) Older adult clients d) A client status post tonsillectomy
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a) Comatose clients Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages. pg. 504
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The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? a) Radiation therapy b) Partial laryngectomy c) Laser surgery d) Total laryngectomy
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d) Total laryngectomy Explanation: In more advanced cases, total laryngectomy may be the treatment of choice. Partial laryngectomy, laser surgery, and radiation therapy are not the treatment of choice for advanced cases of laryngeal cancer. pg.559
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A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: a) Sleep with the head of bed elevated. b) Do not perform saline irrigations to the nares. c) You may drink 1 glass of alcohol daily. d) Caffeinated beverages are allowed.
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a) Sleep with the head of bed elevated. Explanation: General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses. pg.546
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A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to a) Seek medical help if he experiences inability to swallow b) Properly dispose of used tissues c) Place an ice collar on the throat to relieve soreness d) Stay in bed when experiencing a fever
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a) Seek medical help if he experiences inability to swallow Explanation: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority. pg.548
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The nurse is providing discharge instructions to a patient following nasal surgery who has nasal packing. Which of the following discharge instructions would be most appropriate for the patient? a) Administer normal saline nasal drops as ordered. b) Take aspirin for nasal discomfort. c) Decrease the amount of daily fluids. d) Avoid sports activities for 6 weeks.
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d) Avoid sports activities for 6 weeks. Explanation: The nurse instructs the patient to avoid sports activities for 6 weeks. There is no indication for the patient to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The patient should take analgesic agents, such as acetaminophen or NSAIDs, (i.e., ibuprofen or naproxen) to decrease nasal discomfort, not aspirin. The patient does not need to use nasal drops when nasal packing is in place. pg.556
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Stiffness of the neck or inability to bend the neck is referred to as which of the following? a) Aphonia b) Nuchal rigidity c) Dysphagia d) Xerostomia
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b) Nuchal rigidity Explanation: Nuchal rigidity is the stiffness of the neck or inability to bend the neck. Aphonia is impaired ability to use one's voice due to distress or injury to the larynx. Xerostomia is dryness of the mouth from a variety of causes. Dysphagia is difficulty swallowing. pg.538
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A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Limit the amount of protein in the diet." b) "Family members should continue to talk to the client." c) "Oral intake of fluids should be limited for 1 week only." d) "Clean the tracheostomy tube with alcohol and water."
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b) "Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing. pg.563
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You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply. a) Aspiration b) Infection c) Injury to the laryngeal nerve d) Penetration of the anterior tracheal wall e) Absence of secretions
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a) Aspiration b) Infection c) Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall. pg.565
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The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? a) Maintain the client in a low-Fowler's position. b) Encourage oral nutrition on the second postoperative day. c) Assess the tracheostomy cuff for leaks. d) Develop an alternate method of communication.
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d) Develop an alternate method of communication. Explanation: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema. pg.560
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The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised? a) Assess capillary refill. b) Obtain vital signs. c) Auscultate lung sounds. d) Monitor heart rhythm.
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c) Auscultate lung sounds. Explanation: Major goals of intubation are to improve respirations and maintain a patent airway for gas exchange. Regular auscultation of the lung fields is essential in confirming that air is reaching the lung fields for gas exchange. All other options are important to provide assessment data. pg. 507
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Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? a) Mechanical ventilation b) Bilevel positive airway pressure (BiPAP) c) Continuous positive airway pressure (CPAP) d) Oxygen by nasal cannula
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c) Continuous positive airway pressure (CPAP) Explanation: CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea. pg. 554
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The nurse assesses a patient who is bleeding profusely from the nose. The nurse documents this finding as which of the following conditions? a) Dysphagia b) Rhinorrhea c) Xerostomia d) Epistaxis
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d) Epistaxis Explanation: Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Xerostomia refers to dryness of the mouth. Rhinorrhea refers to drainage of a large amount of fluid from the nose. Dysphagia refers to difficulties in swallowing. pg. 554
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A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis? a) Provide a nasal splint. b) Apply direct continuous pressure. c) Place the client in a semi-Fowler's position. d) Apply a moustache dressing.
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b) Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction. pg.555
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Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? a) Referral for counseling b) Emotional support c) Family counseling d) Referral for vocational training
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b) Emotional support Explanation: Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling. pg. 561
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Which of the following postoperative instructions does a nurse provide a patient and family to avoid after a laryngeal surgery? a) Swimming b) Wearing a scarf over the stoma c) Hand-held showers d) Coughing
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a) Swimming Explanation: The nurse provides the patient and family with the following postoperative instructions:water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the patient to avoid swimming and to use a hand-held shower device when bathing. The nurse also suggests that the patient to wear a scarf over the stoma to make the opening less obvious. The nurse encourages the patient to cough every 2 hours to promote effective gas exchange. pg.559
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The nurse is caring for a patient who underwent a laryngectomy. Which of the following interventions will the nurse initially complete in an effort to meet the patient's nutritional needs? a) Offer plenty of thin liquids. b) Encourage sweet foods. c) Initiate enteral feedings. d) Liberally season foods.
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c) Initiate enteral feedings. Explanation: Postoperatively, the patient may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the patient is permitted to resume oral feedings, thin liquids are offered, and sweet food are avoided because they cause increased salivation and decrease the patient's appetite. The patient's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the patient usually accommodates to this change and olfactory sensation adapts; thus, seasonings are based on personal preferences. pg.563
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The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of a) 2 to12 days. b) 0 to 3 months. c) 20 to 30 days. d) 3 to 6 months.
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a) 2 to12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time period 0 to 3 months exceeds the incubation period. The time period 20 to 30 days exceeds the incubation period. The time period 3 to 6 months exceeds the incubation period. pg.542
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A 62-year-old male client with a history of chronic laryngitis arrives at the clinic complaining of a hoarseness "he can't shake." The nurse is aware that this client may be at risk for which of the following conditions? a) Laryngeal cancer b) Peritonsillar abscess c) Adenoiditis d) Coryza
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a) Laryngeal cancer Explanation: The nurse knows that laryngeal cancer is most common in people 60 to 70 years of age, with men affected more frequently than are women. The client's history of chronic laryngitis may also predispose him to the development of laryngeal cancer. Sore throat, difficulty or pain on swallowing, fever, and malaise are the most common symptoms of adenoiditis. Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. This is another term for the common cold. Symptoms include sneezing, sore throat, and nasal congestions. Clients with a peritonsillar abscess experience difficulty and pain with swallowing, fever, malaise, ear pain, and difficulty talking. pg.558
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Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion? a) Simple b) Central c) Mixed d) Obstructive
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d) Obstructive Explanation: Obstructive sleep apnea occurs usually in men, and especially in men who are older and overweight. Types of sleep apnea do not include a simple characterization. Mixed sleep apnea is a combination of central and obstructive apnea with one apneic episode. In central sleep apnea, the patient demonstrates simultaneous cessation of both airflow and respiratory movements. pg.553
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The nurse is caring for a patient admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been completed. Which of the following interventions should the nurse include in the patient's care? a) Restrict fluid intake. b) Apply pressure to the convex of the nose. c) Position the patient in the side-lying position. d) Apply an ice pack.
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d) Apply an ice pack. Explanation: Following a nasal fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. The packing inserted to stop the bleeding may be uncomfortable and unpleasant, and obstruction of the nasal passages by the packing forces the patient to breathe through the mouth. This, in turn, causes the oral mucous membranes to become dry. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. Applying direct pressure is not indicated in this situation. pg.556
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The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? a) "I was chewing ice chips all day long." b) "I used my voice in excess over the weekend." c) "I smoke a pack of cigarettes a day." d) "I have environmental allergies."
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a) "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes. pg. 551
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A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is a) Deficient fluid volume related to increased fluid needs b) Ineffective airway clearance related to excess mucus production c) Acute pain related to upper airway irritation d) Deficient knowledge related to prevention of upper respiratory infections
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b) Ineffective airway clearance related to excess mucus production Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis. pg.540
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A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client? a) "The ET tube will remain in place for at least a day postsurgery." b) "The ET tube will be inserted through an opening in your trachea." c) "The ET tube will be connected to a negative-pressure ventilator." d) "The ET tube will maintain your airway while you're under anesthesia."
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d) "The ET tube will maintain your airway while you're under anesthesia." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or comatose. pg. 504
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Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy? a) Use enteral feedings after the procedure b) Season food to suit an increased sense of taste and smell c) Recommend the long-term use of zinc lozenges d) Offer plenty of thin liquids when intake resumes
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a) Use enteral feedings after the procedure Explanation: Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the patient may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended. pg.560
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You are caring for a client who is 42 years old and status post adenoidectomy. You find the client in respiratory distress when you enter his room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? a) Infection b) Postoperative bleeding c) Plugged tracheostomy tube d) Edema of the upper airway
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d) Edema of the upper airway Explanation: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube. pg.550
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The nurse is caring for a female patient following a tonsillectomy and adenoidectomy. Two hours following the procedure, the patient begins to vomit large amounts of dark blood in frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse will do which of the following? a) Stay with the patient and monitor her closely. b) Obtain a light, mirror, gauze, curved hemostats. c) Prepare for a needle aspiration. d) Orally suction the patient, as needed.
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b) Obtain a light, mirror, gauze, curved hemostats. Explanation: If the patient vomits large amounts of dark blood at frequent intervals, or if the pulse rate and temperature rise, or the patient becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the patient's bedside. Needle aspiration is a procedure considered for patients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time. pg.549
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A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions: a) "You are allowed to have hot tea or coffee." b) "Gargle vigorously to clean your throat." c) "You may have a sore throat for 1 week." d) "Gargle with a warm salt solution."
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d) "Gargle with a warm salt solution." Explanation: A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided. pg. 549
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You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? a) Hardened secretions b) Incrusted mucous membranes c) Erosion of the trachea d) Noisy breathing
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d) Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea. pg.549
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The nurse is caring for a patient in the ICU with a nasotracheal tube. Because of the tube placement, the nurse understands that the patient is at risk for developing which of the following? a) Orbital cellulitis b) Severe epistaxis c) Sinus infection d) Subperiosteal abscess
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c) Sinus infection Explanation: Patients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of patients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the patient's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis. pg.544
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The nurse is assessing a patient in the clinic, and upon physical assessment the patient demonstrates displacement of the sternum. This would be documented as which of the following conditions? a) Kyphoscoliosis b) Pigeon chest c) Funnel chest d) Barrel chest
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b) Pigeon chest Explanation: Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis. A barrel chest is seen in patients with emphysema and occurs as a result of over-inflation of the lungs. A funnel chest occurs when there is a depression in the lower portion of the sternum. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. pg.462
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You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover? a) Visiting hours b) Alternative methods of communication c) Pain before surgery d) Post operative nutrition
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b) Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching. pg.560
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A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: a) sit upright, leaning slightly forward. b) blow his nose and then put lateral pressure on his nose. c) lie supine with his neck extended. d) hold his nose while bending forward at the waist.
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a) sit upright, leaning slightly forward. Explanation: Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it. pg.555
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The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? a) Crackles in the bases of the lungs b) Diminished breath sounds throughout c) Audible stridor without using a stethoscope d) Rhonchi in the bronchial region
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c) Audible stridor without using a stethoscope Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling. pg.472
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The nurse is discussing immediate postoperative communication strategies with a patient scheduled for a total laryngectomy. Which of the following information will the nurse include? a) "After surgery you will have a sore throat, but will be able to speak." b) "A speech therapist will evaluate you and recommend a system of communication after surgery." c) "After surgery, you will have to use an electric larynx to communicate." d) "You can use writing or a communication board to communicate."
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d) "You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the patient must understand that the natural voice will be lost, but that special training can provide a means for communicating. The patient needs to know that until training is started, communication will be possible by using the call light, by writing, or by using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the patient prior to surgery and a method of immediate postoperative communication will be established. pg.563
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A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority? a) Administer one intramuscular injection of penicillin. b) Ask an accompanying homeless friend to monitor the client's follow-up. c) Provide emphatic oral instructions for the client. d) Provide the client with oral penicillin that will last for 5 days.
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a) Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy. pg.547
question
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? a) Aphonia following a football game b) Epistaxis, twice last week c) Laryngitis following a cold d) Hoarseness for 2 weeks
answer
d) Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity. pg.551
question
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.
answer
100 Explanation: The volume of the IV medication is 50 mL. The time for infusion is 30 minutes or 0.5 hr. 50 mL/0.5 hr = 100 mL/1 hr. pg.523
question
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to a) Clean the medication container once each day. b) Blow the nose before applying medication into the nares. c) Tilt the head back when activating the spray of the medication. d) Wait 10 seconds before administering the second spray.
answer
b) Blow the nose before applying medication into the nares. Explanation: The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use. pg.541
question
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for a) Hypertension b) Nuchal rigidity c) Nausea d) Mild headache
answer
b) Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids. pg.544
question
A patient is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include a) hoarseness. b) a moist cough. c) a nonedematous uvula. d) a throat that feels worse in the evening.
answer
a) hoarseness. Explanation: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous. pg.551
question
A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to a) Reassure the client that the nose is not fractured. b) Apply an ice pack to the nose. c) Administer prescribed oral ibuprofen (Motrin). d) Check the clear fluid for glucose.
answer
d) Check the clear fluid for glucose. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribiform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed. pg.556
question
Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy? a) Impaired verbal communication b) Imbalanced nutrition: Less than body requirements c) Anxiety and depression d) Ineffective airway clearance
answer
d) Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but they are not the priority diagnosis. pg.561
question
A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following? a) Respiratory failure (RF) b) Gastroesophageal reflux disease (GERD) c) Congestive heart failure (CHF) d) Chronic obstructive pulmonary disease (COPD)
answer
b) Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult. pg.539
question
A 72-year-old male client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. If laryngeal cancer is suspected, the nurse would be most likely to hear which of the following complaints from the client? a) Headaches in the morning b) Weight loss c) Discomfort when drinking cold liquids d) A feeling of swelling at the back of the throat
answer
d) A feeling of swelling at the back of the throat Explanation: After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may complain of burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache. pg.558
question
Which of the following clinical manifestations of hemorrhage is related to carotid artery rupture? a) Increased blood pressure b) Shallow respirations c) Dry skin d) Increased pulse rate
answer
d) Increased pulse rate Explanation: The nurse monitors vital signs for changes, particularly increased pulse rate, decreased blood pressure, and rapid, deep respirations. Cold, clammy, pale skin may indicate active bleeding. pg.564
question
Your client has had laryngeal surgery. What is as expected outcome in this client? a) The client's suture line remains intact. b) The client can swallow without difficulty. c) The client maintains an adequate caloric intake. d) The client's breathing patterns improve.
answer
c) The client maintains an adequate caloric intake. Explanation: The caloric and fluid intake of a client undergoing laryngeal surgery should be adequate. The suture line and swallowing abilities are evaluated in clients undergoing tonsillectomy and adenoidectomy. Improved breathing patterns are evaluated in the case of clients with trauma in the upper airway. pg.565
question
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has? a) Cancer of the pharynx b) Cancer of the tonsils c) Laryngeal polyps d) Laryngeal cancer
answer
d) Laryngeal cancer Explanation: Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils. pg.558
question
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? a) A nasal cannula b) A face mask c) A rigid shell d) A ventilator
answer
b) A face mask Explanation: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device. pg.494
question
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have a) trouble with your breathing" b) a foul odor to your breath" c) a persistent cough or sore throat" d) difficulty swallowing foods"
answer
c) a persistent cough or sore throat" Explanation: Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath. pg.551
question
Most cases of acute pharyngitis are caused by which of the following? a) Bacterial infection b) Viral infection c) Systemic infection d) Fungal infection
answer
b) Viral infection Explanation: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. pg.546
question
A first-line antibiotic utilized in the treatment of acute sinusitis includes a) Cefzil b) Ceftin c) Augmentin d) Ampicillin
answer
d) Ampicillin Explanation: First-line antibiotics include amoxicillin, ampicillin, and erythromycin. Second-line therapy includes Ceftin, Cefzil, and Augmentin. pg.543
question
The nurse is caring for a male patient diagnosed with rhinosinusitis. The physician has ordered the patient to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the patient that a common side effect of this medication includes which of the following? a) Epistaxis b) Headache c) Watery eyes d) Arthralgia
answer
a) Epistaxis Explanation: Common side effects of budesonide include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasms. pg.544
question
The nurse is caring for a patient receiving radiation therapy for laryngeal cancer. A late complication of radiation therapy includes which of the following? a) Pain b) Dysphasia c) Xerostomia d) Laryngeal necrosis
answer
d) Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy. pg.560
question
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage? a) Warm, moist skin b) Increased blood pressure c) Decreased pulse rate d) Rapid, deep respirations
answer
d) Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding. pg.564
question
A late complication of radiation therapy includes a) xerostomia. b) laryngeal necrosis. c) pain. d) dysphasia.
answer
b) laryngeal necrosis. Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy. pg.560
question
Which of the following nursing diagnoses best encompasses the anticipated psychosocial concerns of a client who is scheduled for a laryngectomy? a) Risk for infection b) Disturbed body image c) Risk for chronic low self-esteem d) Deficient knowledge
answer
b) Disturbed body image Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery. Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. Clients require information prior to their surgery to make appropriate decisions, but this is not considered a psychosocial concern. Clients are at high risk for infection following a laryngectomy, but this is not considered a psychosocial concern. Although chronic low self-esteem may develop following a laryngectomy, depending on the client's ability to cope, a more immediate concern would be related to disturbed body image. pg.561
question
A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to a) Report relief of pain to level 3 using a pain intensity scale of 1 to 10. b) Gargle with a warm saline solution frequently. c) Take acetaminophen with codeine when pain is 5 or above. d) Use a pain intensity rating scale of 0 to 10.
answer
a) Report relief of pain to level 3 using a pain intensity scale of 1 to 10. Explanation: The client statement of relief of pain to level 3 indicates improvement of the problem. The other options are actually interventions or actions that can help achieve a long-term goal of relief of pain. pg.552
question
The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications? a) Tylenol with codeine b) Tylenol c) Robitussin DM d) Penicillin
answer
d) Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are used more often and are as effective and less painful than injections. Penicillin injections are recommended only if there is a concern that the patient will not comply with therapy. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given. pg.547
question
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by a) Instructing the client to tilt the head back with ice applied to the nose b) Applying pressure to the nose for 1 to 2 minutes c) Pinching the upper and hard portion of the nose d) Telling the client to sit upright with the head tilted forward
answer
d) Telling the client to sit upright with the head tilted forward Explanation: Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes. pg.555
question
The nurse is instructing a client who is scheduled for a laryngectomy about methods of alaryngeal speech. Which of the following best describes tracheoesophageal puncture (TEP)? a) It requires the client to hold a throat vibrator against the neck. b) It will result in a low, gruff-sounding voice. c) It enables the client to form words with the lips. d) It requires the insertion of a prosthesis into the trachea.
answer
d) It requires the insertion of a prosthesis into the trachea. Explanation: TEP requires a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device. An artificial larynx is a throat vibrator held against the neck that projects sound into the mouth. With esophageal speech, the client forms words with the lips. Esophageal speech causes the voice quality to be lower pitched and gruff sounding. pg.560
question
The client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. The client is receiving humidified oxygen. A priority nursing diagnosis is: a) impaired gas exchange related to ventilation-perfusion inequality b) ineffective breathing pattern related to inflammatory effects of surgery c) ineffective airway clearance related to excess mucus production d) anxiety related to the effects of surgery and loss of voice
answer
c) ineffective airway clearance related to excess mucus production Explanation: All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority. pg.551
question
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? a) Chronic tonsilittis b) Laryngeal cancer c) Laryngeal polyps d) Chronic pharyngitis
answer
b) Laryngeal cancer Explanation: Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom. pg.558
question
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that: a) adenocarcinoma accounts for most cases of laryngeal cancer. b) inhaling polluted air isn't a risk factor for laryngeal cancer. c) laryngeal cancer occurs primarily in women. d) laryngeal cancer is one of the most preventable types of cancer.
answer
d) laryngeal cancer is one of the most preventable types of cancer. Explanation: Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer. pg.557
question
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? a) Magnetic resonance imaging (MRI) b) Transillumination of the sinus c) CBC with differential d) Nasal culture
answer
b) Transillumination of the sinus Explanation: Transillumination and x-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in the sinus cavity. pg.545
question
When caring for a client who has just had a total laryngectomy, the nurse should plan to: a) encourage oral feedings as soon as possible. b) develop an alternative communication method. c) keep the tracheostomy cuff fully inflated. d) keep the client flat in bed.
answer
b) develop an alternative communication method. Explanation: A client with a laryngectomy can't speak, but still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the client in semi-Fowler's position. pg.560
question
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about a) Cold compresses to the sinus cavities b) Administration of oral antibiotics c) Use of a dehumidifier d) Saline lavages to the nares
answer
d) Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated. pg.543
question
A client is postoperative for a partial laryngectomy following a diagnosed malignancy. The client is to start oral feedings. The nurse does the following interventions: (Select all that apply.) a) Encourages the client to ingest sweet foods b) Provides thick liquids c) Obtains results of a swallow study d) Orders a regular diet tray e) Facilitates privacy while eating
answer
c) Obtains results of a swallow study b) Provides thick liquids Explanation: When a client is allowed to eat following a partial laryngectomy, a swallow study may be obtained first to determine the client's risk of aspiration. The client is started with thick liquids because they are easy to swallow. The nurse stays with the client during initial feedings to ensure safe ingestion. Solid foods are introduced as tolerated. The nurse encourages the client to avoid sweet foods, which increase salivation and suppress appetite. pg.563
question
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first? a) Test the nasal drainage for glucose. b) Have the client blow his nose. c) Look for a halo sign after the drainage dries. d) Contact the physician.
answer
a) Test the nasal drainage for glucose. Explanation: Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment. pg.556
question
Which of the following diagnostic tests is used to confirm the diagnosis of maxillary and frontal sinusitis? a) Sinus aspirates b) MRI c) CT scan d) Sinus x-rays
answer
a) Sinus aspirates Explanation: To confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen, sinus aspirates may be obtained. Flexible endoscopic culture techniques and swabbing of the sinuses have been used for this purpose. Sinus x-rays and CT scans may be obtained for patients with frontal headaches, in refractory cases, and if complications are suspected. pg.543
question
When a patient has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the patient very carefully because he or she is at high risk for a) dehydration. b) carotid artery hemorrhage. c) pulmonary embolism. d) pneumonia.
answer
b) carotid artery hemorrhage. Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient. pg.564
question
A client reports nasal congestion, sneezing, sore throat, and muscle aches. The nurse intervenes how? Select all answers that apply. a) Administer oral ibuprofen (Motrin). b) Recommend guaifenesin (Mucinex). c) Teach the client about handwashing. d) Refer the client to a physician for antibiotic therapy. e) Provide warm salt-water gargles.
answer
e) Provide warm salt-water gargles. a) Administer oral ibuprofen (Motrin). c) Teach the client about handwashing. b) Recommend guaifenesin (Mucinex). Explanation: Described signs and symptoms are consistent with viral rhinitis (the common cold). Management consists of symptomatic therapy, such as gargling with warm salt-water gargles, taking nonsteroidal anti-inflammatory medications (eg, ibuprofen), and using guaifenesin, which promotes removal of secretions. Handwashing is the most effective measure to prevent transmission of organisms. Antibiotics should not be used, because they are not effective against viruses and misuse of antibiotics have contributed to the development of antibiotic-resistant organisms. pg.540
question
The nurse knows that there are three types of chronic pharyngitis. Which of the following is characterized by numerous swollen lymph follicles on the pharyngeal wall? a) Hypertrophic b) Atrophic c) Aphonia d) Chronic granular
answer
d) Chronic granular Explanation: Chronic granular pharyngitis is characterized by numerous swollen lymph follicles on the pharyngeal wall. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane. pg.548
question
Another term for clergyman's sore throat is a) atrophic pharyngitis. b) aphonia. c) chronic granular pharyngitis. d) hypertrophic pharyngitis.
answer
c) chronic granular pharyngitis. Explanation: In clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane. pg.548
question
A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information: a) Severe pain when palpating the sinuses is normal. b) Dehumidify the air in the home. c) Make sure to follow antibiotic therapy. d) Avoid air travel.
answer
d) Avoid air travel. Explanation: Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection. pg.544
question
A patient presents to the ED with a suspected allergic reaction. The patient is experiencing laryngeal edema causing obstruction and is demonstrating retractions in the neck during inspirations. Which of the following is the nurse's priority intervention? a) Apply 100% oxygen via a face mask. b) Prepare for immediate tracheostomy. c) Prepare to administer subcutaneous epinephrine and corticosteroids. d) Prepare for endotracheal intubation with mechanical ventilation.
answer
c) Prepare to administer subcutaneous epinephrine and corticosteroids. Explanation: The use of accessory muscles to maximize airflow is often manifested by retractions in the neck during inspirations and is an ominous sign of impending respiratory distress. The patient's obstruction is caused by edema resulting from an allergic reaction, and treatment should include immediate administration of subcutaneous epinephrine and a corticosteroid. The other interventions may be indicated for a patient with a laryngeal obstruction; however, in this instance the most appropriate intervention to treat the patient's laryngeal edema is the administration of the medications. pg.551
question
A nurse is teaching a client with recurrent rhinosinusitis and instructs the client to take the following medication at the first sign of symptoms: a) oxymetazoline (Afrin) nasal spray b) acetaminophen (Tylenol) c) guaifenesin (Mucinex) d) naproxen (Aleve)
answer
c) guaifenesin (Mucinex) Explanation: The client should take a decongestant (eg, guaifenesin) at the first sign of recurrence of rhinosinusitis to promote drainage of the sinus cavities and prevent bacterial infection. Medications that the client may take later in the illness for pain relief include acetaminophen and nonsteroidal antinflammatory drugs, such as naproxen. Over-the-counter nasal sprays (eg, Afrin) may cause rebound congestion. pg.541
question
A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to: a) Take a hypnotic medication at hours of sleep. b) Eliminate alcohol ingestion. c) Use nasal oxygen at night. d) Sleep on the back.
answer
b) Eliminate alcohol ingestion. Explanation: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea. pg.554
question
A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction? a) "Keep the stoma moist." b) "Keep the stoma uncovered." c) "Have a family member perform stoma care initially until you get used to the procedure." d) "Keep the stoma dry."
answer
a) "Keep the stoma moist." Explanation: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities. pg.563
question
The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal? a) The client will have decreased pain. b) The client will remain alert and oriented. c) The client will have decreased edema. d) The client will have increased tissue perfusion.
answer
c) The client will have decreased edema. Explanation: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply. pg.556
question
Your client has just been diagnosed with laryngeal cancer. The client asks you what causes laryngeal cancer. What would be your best response? a) "Research has shown that habitual resting of the voice contributes to laryngeal cancer." b) "Research has shown that heredity contributes to having laryngeal cancer." c) "A carcinogen associated with laryngeal cancer is allergies." d) "A carcinogen associated with laryngeal cancer is carbon monoxide."
answer
b) "Research has shown that heredity contributes to having laryngeal cancer." Explanation: In addition, chronic laryngitis, habitual overuse of the voice, and heredity may contribute. Carbon monoxide has not been associated with laryngeal cancer. Allergies are not a carcinogen. pg.558
question
A patient has undergone a laryngectomy. The nurse notes evidence of wound breakdown. The nurse understands that the patient is at a high risk for developing which of the following? a) Pneumonia b) Dehydration c) Carotid hemorrhage d) Pulmonary embolism
answer
c) Carotid hemorrhage Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. If wound breakdown occurs, the patient must be monitored carefully and identified as at high risk for carotid hemorrhage. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient. pg.564
question
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? a) Sudden restlessness b) Copious mucous secretions c) Harsh cough d) Rhonchi in lung fields
answer
a) Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions. pg.517
question
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to a) Use a room vaporizer to loosen secretions. b) Report decreased congestion. c) Assume an upright position to facilitate drainage. d) Increase fluid intake.
answer
b) Report decreased congestion. Explanation: A report from the client of decreased congestion indicates improvement of the problem. The other options are actually interventions or actions that the client can undertake to achieve a long-term goal of a patent airway. pg.552
question
You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply. a) Tobacco b) Alcohol c) Age d) Region of country you live in e) Industrial pollutants
answer
b) Alcohol a) Tobacco e) Industrial pollutants Explanation: Carcinogens, such as tobacco, alcohol, and industrial pollutants, are associated with laryngeal cancer. pg.558
question
A client who has been diagnosed with an early glottis cancer would most likely undergo which type of surgery? a) Laser microsurgery b) Partial laryngectomy c) Total laryngectomy d) Vocal cord stripping
answer
a) Laser microsurgery Explanation: In early glottis cancer, early stage lesions are treated and removed with a laser process. This would be the surgical treatment for early stage vocal cord lesions. This surgery is done to treat early-stage laryngeal cancer when only one cord is involved. This surgery is done when the cancer extends beyond the vocal cords. pg.559
question
The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply. a) Increased fluids b) Antibiotics c) Antitussives d) Saline gargles e) Antiemetics f) Rest
answer
a) Increased fluids c) Antitussives d) Saline gargles f) Rest Explanation: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus. pg.541
question
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections? a) Gently blow the nose to eliminate nasal secretions. b) Use an anti-allergy medication to decrease rhinitis. c) Administer an over-the-counter decongestant. d) Place a warm cloth over the sinus area of the forehead.
answer
c) Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best. pg.542
question
Late symptoms of laryngeal cancer include which of the following. Select all that apply. a) Dysphagia b) Burning in throat c) Dyspnea d) Sore throat e) Persistent hoarseness
answer
a) Dysphagia c) Dyspnea e) Persistent hoarseness Explanation: Later symptoms include dysphagia, dyspnea, unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Earlier, the patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. pg.561
question
Which of the following methods most resembles normal speech following a total laryngectomy? a) Esophageal speech b) Blom-Singer voice prosthesis c) Lip speaking d) Electrolarynx held at neck
answer
b) Blom-Singer voice prosthesis Explanation: The Blom-Singer voice prosthesis most resembles normal speech. With esophageal speech, patients compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. With electrolarynx, a battery-powered apparatus projects sound into the oral cavity. When the mouth forms words (articulation), the sounds from the electric larynx becomes audible words. Lip speaking is available during the immediate postoperative period. It does not resemble normal speech. pg.560
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The nurse is assessing a patient for obstructive sleep apnea (OSA). Which of the following are signs and symptoms of OSA? Select all that apply. a) Pulmonary hypotension b) Loud snoring c) Polycythemia d) Evening headaches e) Insomnia
answer
c) Polycythemia b) Loud snoring e) Insomnia Explanation: Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, corpulmonale, polycythemia, and enuresis. pg.554
question
A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by a) Removing the oral airway before the gag reflex has returned for client comfort b) Placing the client prone with the head turned to the side c) Maintaining a warm compress around the client's neck area d) Sitting the client in the semi-Fowler's position
answer
b) Placing the client prone with the head turned to the side Explanation: The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area. pg.549
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You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? a) Psychological status b) Airway patency c) Level of consciousness d) Pain level
answer
b) Airway patency Explanation: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation. pg.565
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A nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching? a) "Wear a tight cloth at the stoma to prevent anything from entering it." b) "Keep the humidity in your house low." c) "Swimming is good exercise after this surgery." d) "Cover the stoma whenever you shower or bathe."
answer
d) "Cover the stoma whenever you shower or bathe." Explanation: The nurse should instruct the client to gently cover the stoma with a loose plastic bib, or even a hand, when showering or bathing to prevent water from entering the stoma. The client should cover the stoma with a loose-fitting, not tight, cloth to protect it. The client should keep his house humidified to prevent irritation of the stoma that can occur in low humidity. The client should avoid swimming, because it's possible for water to enter the stoma and then enter the client's lung, causing him to drown without submerging his face. pg.563
