Med Surg Ch 56 Coordinating Care for Patients With Oral and Esophageal Disorders

A patient admitted to the MedSurg unit. Which diagnosis does the nurse suspect, when a positive shifting dullness during abdominal percussion is noted? a) Ascites b) Liver enlargement c) Pancreatitis d) An abdominal mass

Answer: A

A patient presents to the ED with left upper quadrant (LUQ) pain. Which does the nurse suspect? a) Ruptured spleen b) Pneumonia c) Hepatitis d) Duodenal ulcer

Answer: A

As the nurse is collecting data during the physical assessment, which indicates the patient is experiencing stage 3 stomatitis? a) Oral ulcerations that bleed with minor trauma b) Patchy oral ulceration c) Redness of mucosa d) Tissue necrosis with significant bleeding noted

Answer: A See table 56.1 Grade 1: Able to eat a normal diet with minimal symptoms. Will have redness or mucosa. Grade 2: Will be symptomatic but can eat a modified diet. Patchy oral ulcerations will be present. Grade 3: Symptomatic and unable to eat or drink by mouth. Will present with confluent oral ulcerations that bleed with minor trauma. Grade 4: symptoms are life threatening. Clinical examination will reveal tissue necrosis with significant bleeding; life threatening consequences

Which statement by the patient undergoing external beam radiation indicates the need for further teaching? A. "My grandchildren will not be able to visit because I will be radioactive." B. "This therapy will hopefully decrease the size of the tumor." C. "I will have daily radiation treatments for several weeks." D. "At least this procedure is not painful."

Answer: A Rationale: External beam radiation does not make the patient radioactive, so there are no visiting restrictions based upon this therapy. The goal of this type of treat- ment is to decrease the size and spread of the tumor, and may be provided before or after surgical resection. Treatment is typically several weeks, and there is no pain associated with the actual radiation.

The nurse provides education to a patient who has a hiatal hernia and experiences GERD after eating. Which activity should the nurse instruct this patient to avoid? A. Lying flat after meals B. Eating small, frequent meals that are not spicy C. Sleeping with the HOB elevated 30 degrees D. Taking ranitidine on an empty stomach

Answer: A Rationale: With a hiatal hernia, part of the stomach herniates up through the diaphragm and into the thorax. These patients may experience pain from reflux of ingested foods. Small frequent, bland meals eaten in an upright position help prevent reflux. Patients with hiatal hernia should not eat within two hours before lying down to sleep and should limit fluid intake with meals. H2-receptor antagonists have a slow onset of action and are most effective when taken 60 minutes before eating.

Which consult is of highest priority for the nurse to facilitate for Mr. Rodriguez? A. Social work consult to explore options for Mr. Rodriguez to access health care and obtain medications B. Substance abuse consult to evaluate the need for alcohol counseling C. Nutrition consult to educate Mr. Rodriguez about appropriate dietary choices to decrease his GERD, i.e., coffee and alcohol use D. Dental consult to screen Mr. Rodriguez for suspicious oral lesions to reinforce the importance of maintaining good oral hygiene and regular dental care

Answer: A Rationale: Without access to care, Mr. Rodriguez will not be able to pay for these consults.

A patient is admitted through the ED. The nurse performs an abdominal assessment. Which structures can be assessed by palpation in the right upper quadrant (RUQ)? Select all that apply. a) Liver b) Gallbladder c) Duodenum d) Spleen e) Stomach

Answer: A, B, C

The nurse has requested a dietary consult for a patient with GERD. What statements provide useful dietary information for this patient to manage the GERD symptoms? (Select all that apply.) A. Maintain an ideal body weight. B. Avoid spicy foods. C. Avoid fatty foods. D. A glass of wine after dinner will help you relax. E. A cup of peppermint will help improve digestion.

Answer: A, B, and C Rationale: Obesity contributes to decreased LES pressure, contributing to GERD. Substances/foods that decrease LES pressure are spicy/fatty foods, peppermint, chocolate and alcoholic beverages.

In caring for a patient who sustained a Le Fort fracture, the nurse monitors for which complications? (Select all that apply.) A. TMJ pain B. Esophageal strictures C. Airway obstruction D. Infection E. Dyspepsia

Answer: A, C, and D Rationale: Based upon the location and severity of the oral trauma, the patient is at risk for airway compro- mise, aspiration of teeth, infection, and the inability to consume adequate nutrition. Esophageal strictures and dyspepsia are associated with esophageal trauma and are not seen with oral fractures.

Which clinical manifestations will the nurse expect to find when taking care of a patient diagnosed with oral cancer? (Select all that apply.) A. Pain radiating to the ear B. Otitis media C. Leukoplakia D. Presence of HPV E. Nasal polyposis

Answer: A, C, and D Rationale: Patients with oral cancer encounter cellular changes that may reveal lesions or tumors positive for HPV, erythroplakia, and/or leukoplakia. Otitis media and nasal polyposis are manifestations of allergic rhinitis.

The nurse is assigned these three patients. After report, which patient would the nurse assess first? A. Mr. Andrews - 59-year-old male underwent surgical excision of a tongue lesion, along with partial removal of tongue and wide excision of soft palate tissue and lymph node biopsy. B. Mr. Carlson - 35-year-old male admitted with an acute exacerbation of gastroesophageal reflux disease (GERD). C. Ms Dawson - 48-year-old female who underwent a Nissen fundoplication secondary to a hiatal hernia yesterday and is stable.

Answer: A. Mr. Andrews Rationale: Mr. Andrews should be assessed first as he is at greatest for respiratory complications related to postoperative edema.

Select the type of epithelial cells that line the oral cavity. A. Basal B. Squamous C. Columnar D. Parietal

Answer: B

The nurse is providing care to a patient diagnosed with oral cancer. Which common site of metastasis should the nurse anticipate? a) Skin b) Liver c) Breast d) Brain

Answer: B

Which information obtained by the nurse during the physical assessment is an indication the patient is experiencing stage 1 stomatitis? a) Patchy oral ulceration b) Redness of mucosa c) Oral ulcerations that bleed with minor trauma d) Tissue necrosis with significant bleeding noted

Answer: B See table 56.1 Grade 1: Able to eat a normal diet with minimal symptoms. Will have redness or mucosa. Grade 2: Will be symptomatic but can eat a modified diet. Patchy oral ulcerations will be present. Grade 3: Symptomatic and unable to eat or drink by mouth. Will present with confluent oral ulcerations that bleed with minor trauma. Grade 4: symptoms are life threatening. Clinical examination will reveal tissue necrosis with significant bleeding; life threatening consequences

Mr. Rodriguez has been diagnosed with squamous cell carcinoma on the right side of his tongue and will have a right hemiglossectomy with a right modified radical neck dissection soon after his scheduled tooth extraction followed by radiation. What type of collaborative care referral is of highest priority for Mr. Rodriguez before starting radiation therapy? A. Substance abuse consult B. Dental consult C. Nutrition consult D. Social work consult

Answer: B Rationale: A dental consult is of immediate concern and will provide necessary pretreatment, oral evalu- ation, identification of potential problems, and help educate the patient about the importance of good oral care. Complications related to infection and osteonecrosis can be minimized or prevented with effective dental care.

The nurse implements which interventions to decrease the risk of dumping syndrome in the patient after esophageal resection for cancer? A. Limit diet to clear liquids only. B. Increase protein in diet. C. Increase simple sugars in the diet. D. Provide eight to ten small meals.

Answer: B Rationale: After esophageal surgery, the patient is at risk for dumping syndrome, which leads to diarrhea after meals. Smaller meals, along with a decrease in complex sugars and high in protein and fat, delay gas- tric emptying and prevents dumping syndrome. Clear liquids are not indicated, and too much fluid may exac- erbate dumping syndrome. The patient is typically pro- vided with six meals per day; eight to ten would be too frequent.

In preparing a patient for esophageal manometry, which content does the nurse include in preprocedure teaching? A. This test measures the acid content in your stomach. B. This test measures the pressure and action of the esophagus. C. This test allows a sample of the esophagus to be obtained. D. This test is used only in patients with diagnosed hiatal hernia.

Answer: B Rationale: Esophageal manometry is used to measure esophageal motor activity, and includes readings of LES pressures. Assessment of pH measures acid content. A biopsy includes obtaining a sample of esophageal tissue.

Which statement made by Mr. Rodriguez in the previous case scenario indicates a need for an interprofessional consultation to address his risk of Barrett's esophagus? A. "I have cut back to drinking a six-pack of beer each week." B. "I cannot afford to take Prilosec for my GERD." C. "I could not afford to take my antibiotic when they told me I have H pylori." D. "My girlfriend tells me that I have bad breath."

Answer: B Rationale: Patients with chronic untreated GERD are at risk of developing Barrett's esophagus.

The nurse is preparing to administer morning medications. Which patients would the nurse administer medications to first? select all that apply A. Mr Andrews- Coumadin and Vasotec to be given VIA NG at 1000 B. Mr Carlson - Pepcid 20mg PO due at 1000 C. Ms Dawson- Ancef 1gm IV and Pepcid 20mg IV at 1000

Answer: B & C- Mr. Carlson and Ms. Dawson Rationale: Mr. Carlson and Ms. Dawson only have oral and IV medication that can be administered quickly. Because Mr. Andrews requires several medications via his NG tube, the nurse could administer his medications last. In the event there were any issues with the NG tube, the other patients would have received their medications on time.

The nurse recognizes which risk factors for the development of stomatitis? (Select all that apply.) A. High-fiber diet B. Radiation therapy C. Past history of skin cancer D. Poor dental hygiene E. Smoking

Answer: B, D, and E Rationale: Radiation and chemotherapy increase the incidence of stomatitis due to damage to fast dividing cells in the oral mucosa. Irritants like tobacco, alco- hol, and oral astringents also increase development of stomatitis.

The nurse correlates an increased risk for oral cavity infection in older adults with which of the following organisms? A. Escherichia coli B. Staphylococcus aurous C. Candida albicans D. Pseudomonas aeruginosa

Answer: C

The nurse is assessing a patient admitted to the ED. Which sound would the nurse expect to elicit when percussing the liver? a) Resonance b) Hyperresonance c) Dullness d) Tympany

Answer: C

The nurse is screening Mr. Rodriguez for his risk of developing secondary stomatitis. What information in his history indicates the highest risk for developing secondary stomatitis? A. He is on amitriptyline, and he rinses his mouth after each meal with Listerine. B. He is on Prilosec, and he recently adopted a cat. C. He started radiation therapy 10 days ago, and he is on a methylprednisolone dose pack for poison ivy. D. He is on Triamterene, and his roommate recently moved out.

Answer: C Rationale: Ten days after radiation therapy, Mr. Rodriguez is particularly susceptible to infection and developing viral, bacterial, or fungal infection leading to secondary stomatitis. Adding steroid therapy for poison ivy further increases the immunosuppression.

The nurse is caring for a patient who encountered a minor esophageal injury after accidently swallowing a piece of a chicken bone. The patient will receive medications and nutrition for 4 to 6 days by nasogastric tube to control mucosal damage and promote healing. Which of the following actions should the nurse plan to take first when administer- ing medications through the nasogastric tube? A. Verify the patient's identification and explain the procedure to the patient. B. Flush the nasogastric tube with 30 to 50 mL per hospital policy prior to administering the medication. C. Check the provider's order. D. Prepare the medication for administration.

Answer: C Rationale: The nurse always checks the physician's order before administering a medication. After verification of the order, the RN determines that the medication is appropriate to be given though a nasogastric tube. Certain medications have a delayed action or enteric coating. Check the approved drug reference or agency pharmacy to verify that these medications can be given through a nasogastric tube. If a medication is not available in an elixir form, the nurse prepares the medication by crushing pills or opening capsules and mixing each medication in 15 to 30 ml of water. Confirmation of patient identification, tube placement, residual volume, and presence of bowel sounds are checked. Medication is drawn up with the appropriate catheter-tip syringe and administered to the patient and then flushed with 15 to 30 ml of water. Docu- mentation of medication administration and any pertinent information is completed.

Which data collected by the nurse during the physical assessment indicates the patient is experiencing stage 4 stomatitis? a) Redness of mucosa b) Patchy oral ulceration c) Tissue necrosis with significant bleeding noted d) Oral ulcerations that bleed with minor trauma

Answer: C See table 56.1 Grade 1: Able to eat a normal diet with minimal symptoms. Will have redness or mucosa. Grade 2: Will be symptomatic but can eat a modified diet. Patchy oral ulcerations will be present. Grade 3: Symptomatic and unable to eat or drink by mouth. Will present with confluent oral ulcerations that bleed with minor trauma. Grade 4: symptoms are life threatening. Clinical examination will reveal tissue necrosis with significant bleeding; life threatening consequences

Juan Rodriguez is a 50-year-old man presenting to his health-care provider for a clinic appointment. Mr. Rodriguez has what appears to be a small ulcer on the side of his tongue. It has been there for 2 weeks, and it is painful and not healing. Which nursing assessment parameter for Mr. Rodriguez is not related to his current symptomatology? A. Pain B. Nutrition C. Swallowing D. Vision

Answer: D

When providing care to a patient who is suspected of having a hiatal hernia, which diagnostic test should the nurse anticipate? a) Complete blood count b) Lower abdominal x-ray c) Magnetic resonance imaging (MRI) d) Esophagogastroduodenoscopy (ECG)

Answer: D

Which diagnosis should the nurse anticipate when planning care for this patient who ingested bleach? a) Oral cancer b) Oral trauma c) Esophageal cancer d) Esophageal trauma

Answer: D

The data collected by the nurse during the physical assessment indicates the patient is experiencing stage 2 stomatitis is which? a) Redness of mucosa b) Tissue necrosis with significant bleeding noted c) Oral ulcerations that bleed with minor trauma d) Patchy oral ulceration

Answer: D See table 56.1 Grade 1: Able to eat a normal diet with minimal symptoms. Will have redness or mucosa. Grade 2: Will be symptomatic but can eat a modified diet. Patchy oral ulcerations will be present. Grade 3: Symptomatic and unable to eat or drink by mouth. Will present with confluent oral ulcerations that bleed with minor trauma. Grade 4: symptoms are life threatening. Clinical examination will reveal tissue necrosis with significant bleeding; life threatening consequences

Mr. Rodriguez has received his biopsy results. He has squamous cell carcinoma on the right side of his tongue. His rating according to the TNM clinical classification for oral cancer is T1N1M0. Using the TNM scale, what information will the nurse reinforce with Mr. Rodriguez? A. "Your cancer is 0.5 cm, it has not spread to the lymph nodes, and there is no spread to other sites." B. "Your cancer is 3 cm, the lymph node on the right side of your neck is 4 cm, and the cancer has spread to your jaw." C. "Your cancer is 4 cm, your lymph nodes on both sides are 6 cm, and there is distant spread to the lung." D. "Your cancer is 1 cm, and a lymph node on the right side is 2 cm with no distant metastasis."

Answer: D Rationale: As stated in choice D per the TNM scale listed below (table 56.3). T1 -Less than 2 cm T2 -Greater than 2 cm but not more than 4 cm T3 -Greater than 4 cm T4a -Lip: through cortical bone, inferior alveolar nerve, floor of the mouth, and skin Oral cavity: through cortical bone, deep/ extrinsic muscle of tongue, maxillary sinus, and skin T4b -Masticator space, pterygoid plates, skull base, internal carotid artery N1 -Ipsilateral single less than or equal to 3 cm N2a -Ipsilateral single greater than 3 cm but not more than 6 cm N3 -Greater than 6 cm MX -Distant metastasis cannot be assessed M0 -No distant metastasis M1 -Distant metastasis

The nurse includes which information in the discharge teaching plan for the patient who sustained esophageal trauma? A. Take ordered antibiotics until your temperature is normal. B. Limit pain medications to times of severe pain. C. Check your temperature every other day. D. Notify your provider if increased drainage is noted from that injured area.

Answer: D Rationale: If the wound becomes infected or there is delayed wound healing, there may be increased drainage from the site that requires prompt evaluation. Antibiotics must be taken until all the medications are taken. Pain medications do not need to be limited, as pain can impair intake and nutritional intake. The patient should take their temperature two to three times/day to check for fever.

A nurse working in an endoscopy clinic is screening patients for the risk of developing Barrett's esophagus. The nurse should consider which patient at greatest risk? A. The patient with a 20-year history of alcohol abuse B. The patient with a 30-pack-per-year smoking history C. The patient who ingested lye as a child and is now 47 years old D. The patient who has had untreated GERD for 30 years

Answer: D Rationale: The patient with untreated GERD is at greatest risk. Barrett's esophagus is found in the lower one third of the esophagus, mainly at the gastroesophageal junction (GEJ) and cardiac (first part of the stomach) of the stomach. Long-term exposure to gastric acid reflux causes metaplastic transformation (Barrett's esophagus) that leads to esophageal adenocarcinoma. Alcohol abuse, cigarette smoking, and lye ingestion are risk factors of squamous cell carcinoma of the upper portions of the esophagus.

The nurse correlates which clinical manifestation to type I hiatal hernia? A. Heartburn B. GERD C. Chest pain D. Anorexia

Answer: D Rationale: Type I hiatal hernia (sliding type) is usually acquired through an ongoing process of disruption to the gastroesophageal junction (GEJ), and is associated with GERD, chest pain, regurgitation, and dysphagia. Type II, (rolling type) or paraesophageal hernias are thought to occur due to an anatomic defect that causes improper anchoring of the stomach below the diaphragm. Reflux is not usually present in patients with hiatal hernias because the LES remains secured below the diaphragm. Clinical manifestations include feeling full after eating, feelings of suffocation, and angina type chest pain.

What laboratory results would the nurse need to asses prior to administering medications to Mr. Andrews? A. CBC B. ABG C. Serum Chemistry D. INR

Answer: D. INR Rationale: While all laboratory results are impor- tant, the nurse should assess the INR prior to administering the next does of Coumadin.