MedSurg Chapter 45

Uncontrolled rhythmic movements of the face or limbs

A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?

Ineffective airway clearance related to obstruction by mucus

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

there are usually no symptoms.

A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:

"I'll eat frequent, small, bland meals that are high in fiber."

A client is diagnosed with a hiatal hernia. Which statement indicates effective client teaching about hiatal hernia and its treatment?

maintaining a patent airway.

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, the nurse should assign highest priority to:

The client is free from esophagitis and achalasia.

A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?

Approximately 80 to 120 mL.

A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is:

Gastroesophageal reflux disease

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

Exhibiting hemoglobin A1C 8.2

An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:

Apply pressure to the bleeding site or major associated vessel.

During postoperative neck dissection assessment, the nurse notices excessive bleeding from the dressing site. She suspects possible carotid artery rupture and takes the immediate first step to:

Instruct the client to swish prescribed nystatin (Mycostatin) solution for 1 minute.

A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. The best nursing intervention is to

Lithotripsy

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

Fowler

Postoperatively, a client with a radical neck dissection should be placed in which position?

Stridor

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

Take measures to prevent spreading the lesion to other people.

The client has a chancre on his lips. The nurse instructs the client to

dysphagia.

The most common symptom of esophageal disease is

Avoid eating or drinking 2 hours before bedtime.

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?

chancre.

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is a(n)

Avoid coffee and alcoholic beverages."

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

a canker sore of the oral soft tissues.

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

Tachycardia

Which are accurate clinical manifestations associated with hemorrhage? Select all that apply.

Chronic irritation of the esophagus is a known risk factor.

Which is an accurate statement regarding cancer of the esophagus?

Difficulty swallowing

Which is the primary symptom of achalasia?

Sialadenitis

Which term describes an inflammation of the salivary glands?

Protrusion of the upper stomach into the lower portion of the thorax.

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

Nystatin (Mycostatin)

A patient has been taking a 10-day course of antibiotics for pneumonia. The patient has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the patient about?

Hairy leukoplakia

A patient who is HIV positive comes to the clinic and is experiencing white patches with rough hairlike projections. The nurse observes the lesions on the lateral border of the tongue. What abnormality of the mouth does the nurse determine these lesions are?

Staphylococcus aureus

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

Assess the graft for color and temperature.

The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to

Weakness, diaphoresis, diarrhea 90 minutes after eating

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Increasing difficulty in swallowing

Which of the following is one of the first clinical manifestations of esophageal cancer?

Chancre

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Sialolithiasis

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?