Prepu Chapter 22
Correct response: 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.
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. A feeling of swelling at the back of the throat B. Weight loss C. Discomfort when drinking cold liquids D. Headaches in the morning
Correct response: 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.
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. Take acetaminophen with codeine when pain is 5 or above. C. Gargle with a warm saline solution frequently. D. Use a pain intensity rating scale of 0 to 10.
Correct response: "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.
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 maintain your airway while you're under anesthesia." B. "The ET tube will be inserted through an opening in your trachea." C. "The ET tube will remain in place for at least a day postsurgery." D. "The ET tube will be connected to a negative-pressure ventilator."
Correct response: 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.
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. Adenoiditis C. Coryza D. Peritonsillar abscess
Correct response: 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.
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? A. Apply a moustache dressing. B. Provide a nasal splint. C. Apply direct continuous pressure. D. Place the client in a semi-Fowler's position.
Correct response: "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.
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. "Do you smoke cigarettes, cigars, or a pipe?" B. "Have you strained your voice recently?" C."Do you eat a lot of red meat?" D. "Do you eat spicy foods?"
Correct response: "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.
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? A. "Clean the tracheostomy tube with alcohol and water." B. "Family members should continue to talk to the client." C. "Oral intake of fluids should be limited for 1 week only." D. "Limit the amount of protein in the diet."
Correct response: "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.
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. "Antibiotics will be prescribed, which will make you feel better." B. "Have you tried a topic nasal decongestant; they work well." C. "You should rest, increase your fluids, and take Ibuprofen." D. "Your symptoms should go away soon, just try to get some rest."
Correct response: "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.
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 need to keep my inhaler at the bedside." B. "I should eat a high-protein diet." C. "I should become involved in a weight loss program." D. "I should sleep on my side all night long."
Correct response: 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.
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. Stands behind the worker, who has hands across the neck B. Places both arms around the worker's waist C. Makes a fist with one hand with the thumb outside the fist D. Exerts pressure against the worker's abdomen
Correct response: "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.
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. "Cover the stoma whenever you shower or bathe." D. "Swimming is good exercise after this surgery."
Correct response: Hoarseness of more than 2 week's duration Explanation: 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. Later symptoms include dysphasia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unintentional weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis.
A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator. A.Hoarseness of more than 2 week's duration B. Dysphasia C. Persistent ulceration D. Cervical lymph adenopathy
Correct response: An antiviral agent such as acyclovir Explanation: Herpes labialis is an infection that is caused by herpes simplex virus type 1 (HSV-1). It is characterized by an eruption of small, painful blisters on the skin of the lips, mouth, gums, tongue, or the skin around the mouth. The blisters are commonly referred to as cold sores or fever blisters. Medications used in the management of herpes labialis include acyclovir (Zovirax) and valacyclovir (Valtrex), which help to minimize the symptoms and the duration or length of flare-up.
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection? A. An antiviral agent such as acyclovir B. An antibiotic such as amoxicillin C. An antihistamine such as Benadryl D. An ointment such as bacitracin
Correct response: Partial laryngectomy Explanation: A partial laryngectomy (laryngofissure-thyrotomy) is often used for patients in the early stages of cancer in the glottis area when only one vocal cord is involved.
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education? A. Total laryngectomy B. Cordectomy C. Vocal cord stripping D.Partial laryngectomy
Correct response: Applying nasal packing Explanation: A nasal fracture very often produces bleeding from the nasal passage. As a rule, bleeding is controlled with the use of packing.
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. Preparing the patient for a septoplasty B. Applying nasal packing C. Administering nasal lavage D.Applying steroidal nasal spray
Correct response: "Radiation is used to shrink the tumor size and is an adjunct to surgery." Explanation: Radiation therapy may also be used preoperatively to reduce the tumor size. Radiation therapy is combined with surgery in advanced laryngeal cancer as adjunctive therapy to surgery or chemotherapy and as a palliative measure.
A patient with an advanced laryngeal tumor is to have radiation therapy. The patient tells the nurse, "If I am going to have radiation, I won't need surgery." What is the best response by the nurse? "That is correct. The radiation will eradicate the tumor and you won't have to have further treatment." "Radiation is used to shrink the tumor size and is an adjunct to surgery." "All patients have to have radiation before they have surgery. It is protocol." "You really don't have to have radiation but you won't have to have such invasive surgery if you have the radiation first."
Correct response: 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.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? A. Bleeding B. Difficulty swallowing C. Throat pain D. Difficulty talking
Correct response: Dysphagia Dyspnea 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.
Late symptoms of laryngeal cancer include which of the following. Select all that apply. A. Dysphagia B. Dyspnea C. Persistent hoarseness D. Sore throat E. Burning in throat
Correct response: 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.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? A. Emotional support B. Referral for counseling C. Family counseling D. Referral for vocational training
Correct response: Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Explanation: Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.
Select the nursing diagnosis that would warrant immediate health care provider notification. A.Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation B. Acute pain related to upper airway irritation secondary to an infection C. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever D. Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care
Correct response: 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.
The antibiotic of choice utilized in the treatment of acute bacterial rhinosinusitis (ABRS) includes which of the following? A. Amoxicillin (Augmentin) B. Levofloxacin (Levaquin) C. Keflex (Cephalexin) D. Ceftin (Cefuroxime)
Correct response: 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.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? A. Partial laryngectomy B. Laser surgery C. Radiation therapy D. Total laryngectomy
Correct response: 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.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of A. 0 to 3 months. B. 20 to 30 days. C. 2 to12 days. D. 3 to 6 months.
Correct response: 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.
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. Apply an ice pack. B. Restrict fluid intake. C. Position the patient in the side-lying position. D. Apply pressure to the convex of the nose.
Correct response: 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 importa
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. Obtain vital signs. B. Monitor heart rhythm. C. Auscultate lung sounds. D. Assess capillary refill.
Correct response: Swimming Explanation: Swimming is not recommended because a person with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. The nurse also suggests that the patient 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.
The nurse is providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following? A. Wearing a plastic bib while showering B. Wearing a scarf over the stoma C. Swimming D. Coughing
Correct response: Comatose clients Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages.
What client would be most in need of an endotracheal tube? A. A client status post tonsillectomy B. Ambulatory clients C. Older adult clients D. Comatose clients
Correct response: Ensure mouth breathing Explanation: For a patient who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating mouth breathing. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.
Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction? A. Apply a warm pack postoperatively B. Ensure mouth breathing C. Apply pressure to the convex portion of the nose D. Provide a splint postoperatively
Correct response: Drainage is Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? A. The stoma is healed, about 6 weeks after surgery. B. The surgical site is dry with encrustations. C. Drainage is D. The patient is able to assist with his own suctioning.
Correct response: 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.
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? A. Airway patency B. Level of consciousness C. Psychologic status D. Pain level
Correct response: 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.
You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? A. Incrusted mucous membranes B. Hardened secretions C. Erosion of the trachea D. Noisy breathing