NUR 4770- Exam 1: PrepU Ch. 22 Managment of Pts w/URT D/Os

2. A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx? A. Deviated trachea B. Facial pain C. Sore throat D. Nausea

Sore throat Rationale: Hoarseness of more than 2 weeks' duration is a common symptom in the client with cancer of the larynx because the tumor impedes the action of the vocal cords during speech. Nausea is not a symptom of laryngeal cancer. Pain radiating to the ear and not to the face may occur if metastasis has occurred. A lump may be felt in the neck but the trachea is not affected.

8. 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. a persistent cough or sore throat" B. difficulty swallowing foods" C. a foul odor to your breath" D. trouble with your breathing"

a persistent cough or sore throat" Rationale: 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

23. When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for A. pneumonia. B. carotid artery hemorrhage. C. dehydration. D. pulmonary embolism.

carotid artery hemorrhage. Rationale: 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 client.

7. An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for: A. 8 seconds with 4 episodes/hour. B. 4 seconds with 2 episodes/hour. C. 10 seconds with 5 episodes/hour. D. 6 seconds with 3 episodes/hour.

10 seconds with 5 episodes/hour. Rationale: OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

16. 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. Wait 10 seconds before administering the second spray. B. Clean the medication container once each day. C. Blow the nose before applying medication into the nares. D. Tilt the head back when activating the spray of the medication.

Blow the nose before applying medication into the nares. Rationale: 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.

17. The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which 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.

It requires the insertion of a prosthesis into the trachea. Rationale: 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.

14. Most cases of acute pharyngitis are caused by which of the following? A. Viral infection B. Bacterial infection C. Systemic infection D. Fungal infection

Viral infection Rationale: Most cases of acute pharyngitis are caused by viral infection. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus.

24. Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy? A. Season food to suit an increased sense of taste and smell B. Offer plenty of thin liquids when intake resumes C. Use enteral feedings after the procedure D. Recommend the long-term use of zinc lozenges

Use enteral feedings after the procedure Rationale: 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 client 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.

4. The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? A. Harsh cough B. Copious mucous secretions C. Sudden restlessness D. Bilateral breath sounds present

Sudden restlessness Rationale: 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. Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.

11. The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? A. "After surgery you will have a sore throat, but you will be able to speak." B. "A speech therapist will evaluate you and recommend a system of communication after surgery." C. "You can use writing or a communication board to communicate." D. "After surgery you will have to use an electric larynx to communicate."

"You can use writing or a communication board to communicate." Rationale: If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.

10. The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient? A. Affected voice sounds B. Enlarged cervical nodes C. Burning of the throat when hot liquids are ingested D. Dysphagia

Affected voice sounds Rationale: Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. However, affected voice sounds are not always early signs of subglottic or supraglottic cancer. The patient may report a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.

5. A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about? A. Cefuroxime B. Amoxicillin-clavulanic acid C. Cephalexin D. Clarithromycin

Amoxicillin-clavulanic acid Rationale: Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.

22. The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care? A. Apply pressure to the convex of the nose. B. Position the patient in the side-lying position. C. Apply an ice pack. D. Restrict fluid intake.

Apply an ice pack. Rationale: Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client 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 client 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.

15. 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.

Check the clear fluid for glucose. Rationale: 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 cribriform 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.

19. The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is A. Epistaxis B. Arthralgia C. Watery eyes D. Headache

Epistaxis Rationale: Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.

34. 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 degrees." This assists in meeting which nursing goal? A. The client will have decreased edema. B. The client will have increased tissue perfusion. C. The client will have decreased pain. D. The client will remain alert and oriented.

The client will have decreased edema. Rationale: Elevating the head of the bed 45 degrees 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.

18. Which is the priority nursing diagnosis for a client undergoing a laryngectomy? A. Anxiety and depression B. Ineffective airway clearance C. Impaired verbal communication D. Imbalanced nutrition: Less than body requirements

Ineffective airway clearance Rationale: 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 the question is asking for the priority nursing diagnosis for this patient. The priority is to identify any issues related to impaired airway.

9. 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.

100 Rationale: 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.

20. 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 the client with oral penicillin that will last for 5 days. D. Provide emphatic oral instructions for the client.

Administer one intramuscular injection of penicillin. Rationale: 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.

21. A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks? A. Applying nasal packing B. Preparing the patient for a septoplasty C. Applying steroidal nasal spray D. Administering nasal lavage

Applying nasal packing Rationale: A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.

29. 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. Chronic granular B. Hypertrophic C. Atrophic D. Aphonia

Chronic granular Rationale: 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.

25. Which clinical manifestation of hemorrhage is related to carotid artery rupture? A. Shallow respirations B. Increased blood pressure C. Increased pulse rate D. Dry skin

Increased pulse rate Rationale: 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.

3. The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply. A. Insomnia B. Pulmonary hypotension C. Evening headaches D. Loud snoring E. Polycythemia

Insomnia Loud snoring Polycythemia Rationale: 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, , polycythemia, and enuresis.

27. 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. Decreased pulse rate B. Warm, moist skin C. Rapid, deep respirations D. Increased blood pressure

Rapid, deep respirations Rationale: 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.

12. 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 0 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 1 to 10.

Report relief of pain to level 3 using a pain intensity scale of 0 to 10. Rationale: 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.

1. Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis? A. CT scan B. Sinus aspirates C. Sinus x-rays D. MRI

Sinus aspirates Rationale: Sinus aspirates may be obtained to confirm the diagnosis of maxillary and frontal sinusitis and identify the pathogen. 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 clients with frontal headaches, in refractory cases, and if complications are suspected.

32. 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. Contact the physician. B. Look for a halo sign after the drainage dries. C. Test the nasal drainage for glucose. D. Have the client blow his nose.

Test the nasal drainage for glucose. Rationale: 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.

33. Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare: A. Clear, warm liquids to slowly stimulate peristalsis. B. Solid foods, so chewing can be reestablished to stimulate salivation. C. Soft, pureed foods, similar in consistency to baby food. D. Thick liquids that are easy to swallow.

Thick liquids that are easy to swallow. Rationale: Feedings are gradually introduced beginning with thick liquids. Soft, pureed foods are added as tolerated. Sweet foods should be avoided.

31. The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled: A. In 2 to 3 weeks. B. Within 24 hours. C. Within 1 week. D. After 1 month.

Within 1 week. Rationale: Surgical reduction of a fracture should occur immediately. However, with significant edema present, surgery can be delayed up to 7 days to allow time for the fluid to resolve. After 1 week, if the fracture is misaligned, rhinoplasty will be necessary to reshape the external appearance of the nose.

26. A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include A. a nonedematous uvula. B. a sore throat that feels worse in the evening. C. a moist cough. D. hoarseness.

hoarseness. Rationale: Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a sore throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.

30. A late complication of radiation therapy is A. laryngeal necrosis. B. xerostomia. C. dysphasia. D. pain.

laryngeal necrosis. Rationale: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.

6. The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing A. sinus infection. B. subperiosteal abscess. C. orbital cellulitis. D. severe epistaxis.

sinus infection. Rationale: Clients with nasotracheal and nasogastric tubes in place are at risk for developing sinus infections. Thus, accurate assessment of clients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the client'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.

13. A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern? A. Impaired gas exchange B. Ineffective airway clearance C. Ineffective breathing pattern D. Anxiety

Ineffective airway clearance Rationale: 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 the highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.

28. 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. laryngeal cancer is one of the most preventable types of cancer. B. adenocarcinoma accounts for most cases of laryngeal cancer. C. laryngeal cancer occurs primarily in women. D. inhaling polluted air isn't a risk factor for laryngeal cancer.

laryngeal cancer is one of the most preventable types of cancer. Rationale: 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.