chapter 18 respiratory upper
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
Hoarseness for 2 weeks
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare:
Thick liquids that are easy to swallow.
The nurse is caring for a client who has had a laryngectomy to treat laryngeal cancer. What instruction should the nurse include in the teaching about the neck stoma?
"Use humidification of the environment to prevent crusting around the stoma."
What client would be most in need of an endotracheal tube? a. Older adult clients b. Ambulatory clients c. Comatose clients d. A client status post tonsillectomy
c
Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?
laryngeal cancer
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?
Auscultate lung sounds.
Which of the following methods most resembles normal speech following a total laryngectomy?
Blom-Singer voice prosthesis
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?
Sore throat
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. Partial laryngectomy b. Cordectomy c. Total laryngectomy d. Vocal cord stripping
a
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. Rapid, deep respirations b. Increased blood pressure c. Decreased pulse rate d. Warm, moist skin
a
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid a. swimming. b. wearing a plastic bib while showering. c. wearing a scarf over the stoma. d. coughing.
a
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. carotid artery hemorrhage. b. pulmonary embolism. c. pneumonia. d. dehydration.
a
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. Take acetaminophen with codeine when pain is 5 or above. b. Report relief of pain to level 3 using a pain intensity scale of 0 to 10. c. Gargle with a warm saline solution frequently. d. Use a pain intensity rating scale of 1 to 10.
b
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for a. Nausea b. Nuchal rigidity c. Hypertension d. Mild headache
b
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include a. a nonedematous uvula. b. hoarseness. c. a moist cough. d. a sore throat that feels worse in the evening.
b
Another term for clergyman's sore throat is a. atrophic pharyngitis. b. chronic granular pharyngitis. c. aphonia. d. hypertrophic pharyngitis.
b
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes a. Congestive heart failure (CHF) b. Respiratory failure (RF) c. Gastroesophageal reflux disease (GERD) d. Chronic obstructive pulmonary disease (COPD)
c
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. Anxiety b. Impaired gas exchange c. Ineffective airway clearance d. Ineffective breathing pattern
c
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of a. 3 to 6 months b. 20 to 30 days c. 2 to 12 days d. 1 to 3 months
c
A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention? a. Prepare for endotracheal intubation with mechanical ventilation. b. Apply 100% oxygen via a face mask. c. Prepare for immediate tracheostomy. d. Prepare to administer subcutaneous epinephrine and corticosteroids
d
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 ointment such as bacitracin b. An antibiotic such as amoxicillin c. An antihistamine such as Benadryl d. An antiviral agent such as acyclovir
d
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: a. The voice was spared and a tracheostomy would be in place until the airway was established. b. A portion of the vocal cord was removed. c. One vocal cord was removed along with a portion of the larynx. d. A permanent tracheal stoma would be necessary.
d
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? a. Difficulty talking b. Difficulty swallowing c. Throat pain d. Bleeding
d
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? a. Pulmonary hypotension b. Increased smooth muscle contractility c. Systemic hypotension d. Hypercapnia
d
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. trouble with your breathing" b. difficulty swallowing foods" c. a foul odor to your breath" d. a persistent cough or sore throat"
d
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. Arthralgia b. Watery eyes c. Headache d. Epistaxis
d
The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect? a. Plugged tracheostomy tube b. Postoperative bleeding c. Infection d. Edema of the upper airway
d
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? a. Keflex b. Levofloxacin c. Ceftin d. Amoxicillin
d
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
noisy breathing
A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to a. Sleep on the back. b. Eliminate alcohol ingestion. c. Take a hypnotic medication at hours of sleep. d. Use nasal oxygen at night
b
Most cases of acute pharyngitis are caused by which of the following? a. Systemic infection b. Viral infection c. Bacterial infection d. Fungal infection
b
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? a. Take aspirin for nasal discomfort. b. Avoid sports activities for 6 weeks. c. Administer normal saline nasal drops as ordered. d. Decrease the amount of daily fluids.
b
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? a. Provide a splint postoperatively b. Ensure mouth breathing c. Apply pressure to the convex portion of the nose d. Apply a warm pack postoperatively
b
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 increased tissue perfusion. b. The client will have decreased pain. c. The client will have decreased edema. d. The client will remain alert and oriented.
c
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. Ask an accompanying homeless friend to monitor the client's follow-up. b. Administer one intramuscular injection of penicillin. c. Provide emphatic oral instructions for the client. d. Provide the client with oral penicillin that will last for 5 days.
b
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. severe epistaxis. b. sinus infection. c. subperiosteal abscess. d. orbital cellulitis.
b
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? a. A nasal cannula b. A face mask c. A rigid shell d. A ventilator
b
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. 4 seconds with 2 episodes/hour. b. 8 seconds with 4 episodes/hour. c. 10 seconds with 5 episodes/hour. d. 6 seconds with 3 episodes/hour.
c
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 will result in a low, gruff-sounding voice. b. It requires the insertion of a prosthesis into the trachea. c. It requires the client to hold a throat vibrator against the neck. d. It enables the client to form words with the lip
b
The nurse is teaching a group of new parents about common colds. Which of the following should be included as treatment options?
antihistamines
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? a. Copious mucous secretions b. Sudden restlessness c. Harsh cough d. Bilateral breath sounds present
b
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? a. Aphonia following a football game b. Hoarseness for 2 weeks c. Laryngitis following a cold d. Epistaxis, twice last week
b
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? a. Level of consciousness b. Pain level c. Airway patency d. Psychologic status
c
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?
c-pap
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about a. Use of a dehumidifier b. Saline lavages to the nares c. Cold compresses to the sinus cavities d. Administration of oral antibiotics
b
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. Arthralgia b. Epistaxis c. Headache d. Watery eyes
b
Which clinical manifestation of hemorrhage is related to carotid artery rupture? a. Increased pulse rate b. Shallow respirations c. Increased blood pressure d. Dry skin
a
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis? a. Pseudomonas aeruginosa b. Staphylococcus aureus c. Group A, beta-hemolytic streptococci d. Gram-negative Klebsiella
c
The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs? a. Encourage sweet foods. b. Liberally season foods. c. Offer plenty of thin liquids. d. Initiate enteral feedings.
d
The nurse is caring for a client who has been diagnosed with an early glottis cancer. The nurse knows the client will likely undergo which type of surgery?
cordectomy
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? a. "You may have a sore throat for 1 week." b. "You are allowed to have hot tea or coffee." c. "Decrease oral intake if increased swallowing occurs." d. "Gargle with a warm salt solution."
d
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? a. "The ET tube will be connected to a negative-pressure ventilator." b. "The ET tube will maintain your airway while you're under anesthesia." c. "The ET tube will be inserted through an opening in your trachea." d. "The ET tube will remain in place for at least a day postsurgery."
b
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: a. blow his nose and then put lateral pressure on his nose. b. hold his nose while bending forward at the waist. c. sit upright, leaning slightly forward. d. lie supine with his neck extended.
c
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 steroidal nasal spray c. Applying nasal packing d. Administering nasal lavage
c
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. inhaling polluted air isn't a risk factor for laryngeal cancer. b. laryngeal cancer occurs primarily in women. c. laryngeal cancer is one of the most preventable types of cancer. d. adenocarcinoma accounts for most cases of laryngeal cancer
c
Select the nursing diagnosis that would warrant immediate health care provider notification. a. Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care b. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever c. Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation d. Acute pain related to upper airway irritation secondary to an infection
c
The nurse is teaching a group of nursing students about bacterial infection which occurs in about 70% of clients who have acute rhinosinusitis. The nursing student is correct when stating that the least common bacteria is: a. Aspergillus fumigatus b. Streptococcus pneumonia c. Hemophilus influenza d. Staphylococcus aureus
d
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. Hypertrophic b. Atrophic c. Aphonia d. Chronic granular
d
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?
Affected voice sounds
The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose? a. Transillumination of the sinus b. CBC with differential c. Nasal culture d. Magnetic resonance imaging (MRI)
a
The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy? a. Laryngeal necrosis b. Pain c. Dysphasia d. Xerostomia
a
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? a. impaired verbal communication b. risk for infection c. risk for chronic low self-esteem d. deficient knowledge
a
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
bleeding
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer? a. a feeling of swelling at the back of the throat b. headaches in the morning c. discomfort when drinking cold liquids d. weight loss
a
A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present? a. The nasal mucosa b. The frontal sinuses c. The tracheal mucosa d. The buccal mucosa
a
Which is the priority nursing diagnosis for a client undergoing a laryngectomy?
Ineffective airway clearance
A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is
Ineffective airway clearance related to excess mucus production
The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?
Initiate enteral feedings.
A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to
Report decreased congestion.
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?
the client will have decreased edema