Nose/face fx, epistaxis
A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.
A
A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.
A
A patient had an open reduction repair of a bilateral nasal fracture. The nurse plans to implement an intervention that focuses on both nursing and medical goals for this patient. Which intervention should the nurse implement? a. Apply an external splint to the nose. b. Insert plastic nasal implant surgically. c. Humidify the air for mouth breathing. d. Maintain surgical packing in the nose
A
The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. What should the nurse do first? a. Test the drainage for the presence of glucose. b. Suction the nose to maintain airway clearance. c. Document the findings and continue monitoring. d. Apply a drip pad and reassure the patient this is normal.
A
While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowlers position. d. Ask the client to perform deep-breathing exercises.
A
A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.
A,B,C,D
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. You will need to cut the wires if you start vomiting. b. Eat six soft or liquid meals each day while recovering. c. Irrigate your mouth every 2 hours to prevent infection. d. Sleep in a semi-Fowlers position after the surgery. e. Gargle with mouthwash that contains Benadryl once a day.
A,B,C,D
A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident
A,C,D,E
A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin
A,D
A patient is being discharged from the emergency department after being treated for epistaxis. In teaching the family first aid measures in the event the epistaxis would recur, what measures should the nurse suggest (select all that apply)? a. Tilt patient's head backwards. b. Apply ice compresses to the nose. c. Tilt head forward while lying down. d. Pinch the entire soft lower portion of the nose. e. Partially insert a small gauze pad into the bleeding nostril.
A,D
The nurse teaches a 66-year-old man with hypertension and osteoarthritis about actions to prevent and control epistaxis. Which statement, if made by the patient, indicates further teaching is required? a. "I should avoid using ibuprofen (Motrin) for pain and discomfort." b. "It is important for me to take my blood pressure medication every day." c. "I will sit down and pinch the tip of my nose for at least 10 to 15 minutes." d. "If I get a nosebleed, I will lie down flat and raise my feet above my heart."
D
A nurse assesses a client who has developed epistaxis. Which conditions in the clients history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets
B,C,D
A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the clients pain level. b. Keep the clients head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the clients cheek.
D
A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency
D
