Chapter 22: Management of Patients with Upper Respiratory Tract Disorders
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care? A.) Develop an alternate method of communication. B.) Encourage oral nutrition on the second postoperative day. C.) Maintain the client in a low-Fowler's position. D.) Assess the tracheostomy cuff for leaks.
Answer: A.) Develop an alternate method of communication.
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
Answer: A.) Hoarseness of more than 2 week's duration
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? A.) impaired verbal communication B.) deficient knowledge C.) risk for infection D.) risk for chronic low self-esteem
Answer: A.) impaired verbal communication
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub? A.) No fluid is normally present B.) 20 mL or less C.) 20-40 mL D.) More than 40 mL
Answer: B.) 20 mL or less
A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect? A.) Metoprolol succinate (Toprol XL) B.) Amlodipine (Norvasc) C.) Enalapril (Vasotec) D.) Valsartan (Diovan)
Answer: C.) Enalapril (Vasotec) Rationale: Use of ACE inhibitors, such as enalapril (Vasotec), is a risk factor for laryngeal obstruction resulting from edema of the throat as a result of a side effect of the drug.
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.) Hypertension B.) Mild headache C.) Nuchal rigidity D.) Nausea
Answer: C.) Nuchal rigidity rationale: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to A.) Stay in bed when experiencing a fever B.) Properly dispose of used tissues C.) Seek medical help if he experiences inability to swallow D.) Place an ice collar on the throat to relieve soreness
Answer: C.) Seek medical help if he experiences inability to swallow Rationale: The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? A.) "I have environmental allergies." B.) "I smoke a pack of cigarettes a day." C.) "I used my voice in excess over the weekend." D.) "I was chewing ice chips all day long."
Answer: D.) "I was chewing ice chips all day long." Rationale: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.
The nurse is 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
Answer: D.) Noisy breathing Rationale: 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.
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
Answer: D.) Partial laryngectomy Rationale: 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.
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.) Soft, pureed foods, similar in consistency to baby food. C.) Solid foods, so chewing can be reestablished to stimulate salivation. D.) Thick liquids that are easy to swallow.
Answer: D.) 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.
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
Answer: D.) Total laryngectomy Rationale: 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.
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include A.) hoarseness. B.) a moist cough. C.) a sore throat that feels worse in the evening. D.) a nonedematous uvula.
Answer: A.) hoarseness.
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.) Avoid sports activities for 6 weeks. B.) Decrease the amount of daily fluids. C.) Take aspirin for nasal discomfort. D.) Administer normal saline nasal drops as ordered.
Answer: A.) Avoid sports activities for 6 weeks. Rationale: The nurse instructs the client to avoid sports activities for 6 weeks. There is no indication for the client to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The client should take analgesic agents, such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen), to decrease nasal discomfort, not aspirin. The client does not need to use nasal drops when nasal packing is in place.
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
Answer: A.) Bleeding Rationale: 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.
A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for: A.) Fever B.) Headache C.) Myalgias D.) Nausea
Answer: A.) Fever Rationale: The signs and symptoms described are consistent with acute pharyngitis. The nurse needs to assess for a fever higher than 39.3°C. Findings will help to determine if the client requires antibiotic therapy. The client may also experience headache, myalgias, and nausea. The nurse needs to assess for these symptoms also, and symptomatic treatment would then be provided.
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
Answer: A.) Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Rationale: Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.
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.) Initiate enteral feedings. B.) Offer plenty of thin liquids. C.) Encourage sweet foods. D.) Liberally season foods.
Answer: A.) Initiate enteral feedings. Rationale: Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: A.) Sleep with the head of bed elevated. B.) Caffeinated beverages are allowed. C.) You may drink 1 glass of alcohol daily. D.) Do not perform saline irrigations to the nares.
Answer: A.) Sleep with the head of bed elevated.
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
Answer: A.) Stands behind the worker, who has hands across the neck Rationale: 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 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.) weight loss C.) discomfort when drinking cold liquids D.) headaches in the morning
Answer: A.) a feeling of swelling at the back of the throat Rationale: 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 report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.
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.) trouble with your breathing" D.) a foul odor to your breath"
Answer: A.) a persistent cough or sore throat"
A nurse is teaching a client with recurrent rhinosinusitis. What medication will the nurse instruct the client to take at the first sign of symptoms? A.) guaifenesin B.) acetaminophen C.) oxymetazoline nasal spray D.) naproxen
Answer: A.) guaifenesin
A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis? A.) interference with sinus drainage B.) excessive protein intake C.) more than 8 hours of sleep per night D.) increased exposure to the health care environment
Answer: A.) interference with sinus drainage
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."
Answer: B.) "Family members should continue to talk to the client."
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? A.) "That is correct. The radiation will eradicate the tumor and you won't have to have further treatment." B.) "Radiation is used to shrink the tumor size and is an adjunct to surgery." C.) "All patients have to have radiation before they have surgery. It is protocol." D.) "You really don't have to have radiation but you won't have to have such invasive surgery if you have the radiation first."
Answer: B.) "Radiation is used to shrink the tumor size and is an adjunct to surgery." Rationale; 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 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
Answer: B.) 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.
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? A.) Cancer of the pharynx B.) Laryngeal cancer C.) Laryngeal polyps D.) Cancer of the tonsils
Answer: B.) Laryngeal cancer
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."
Answer: C.) "I should become involved in a weight loss program."
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: A.) One vocal cord was removed along with a portion of the larynx. B.) The voice was spared and a tracheostomy would be in place until the airway was established. C.) A permanent tracheal stoma would be necessary. D.) A portion of the vocal cord was removed.
Answer; C.) A permanent tracheal stoma would be necessary. Rationale: A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy.
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 A.) Acute pain related to upper airway irritation B.) Deficient fluid volume related to increased fluid needs C.) Deficient knowledge related to prevention of upper respiratory infections D.) Ineffective airway clearance related to excess mucus production
Answer: D.) Ineffective airway clearance related to excess mucus production
A client comes into the emergency department with epistaxis. What intervention should the nurse 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.
Answer: C.) Apply direct continuous pressure.
Late symptoms of laryngeal cancer include which of the following. Select all that apply. - Dysphagia - Dyspnea - Persistent hoarseness - Sore throat - Burning in throat
Answer: - Dysphagia - Dyspnea - Persistent hoarseness Rationale: 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.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of A.) 2 to 12 days B.) 20 to 30 days C.) 1 to 3 months D.) 3 to 6 months
Answer: A.) 2 to 12 days Rationale: HSV-1 is transmitted primarily by direct contact with infected secretions. The incubation period is about 2 to 12 days. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? A.) Amoxicillin B.) Levofloxacin C.) Keflex D.) Ceftin
Answer: A.) Amoxicillin
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.) dehydration. D.) pneumonia.
Answer: A.) carotid artery hemorrhage.
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is A.) ampicillin. B.) amoxicillin-clavulanic acid. C.) cefprozil. D.) cefuroxime.
Answer: B.) amoxicillin-clavulanic acid.
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? A.) Hand-held showers B.) Wearing a scarf over the stoma C.) Swimming D.) Coughing
Answer: C.) Swimming Rationale: The nurse provides the client and family with the following postoperative instructions: water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.
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.
Answer: C.) Auscultate lung sounds.
Which assessment finding puts a client at increased risk for epistaxis? A.) Use of a humidifier at night B.) Hypotension C.) Cocaine use D.) History of nasal surgery
Answer: C.) Cocaine use
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 <30 mL/day for 2 consecutive days. D.) The patient is able to assist with his own suctioning.
Answer: C.) Drainage is <30 mL/day for 2 consecutive days.
You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? A.) Infection B.) Post operative bleeding C.) Edema of the upper airway D.) Plugged tracheostomy tube
Answer: C.) Edema of the upper airway
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.) Infection B.) Postoperative bleeding C.) Edema of the upper airway D.) Plugged tracheostomy tube
Answer: C.) Edema of the upper airway Rationale: With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.
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.) Aphonia B.) Chronic granular C.) Atrophic D.) Hypertrophic
ANSWER: B.) 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.
Which is a priority nursing intervention that the nurse should perform for a client 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
Answer: B.) Ensure mouth breathing
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? A.) "Gargle with a warm salt solution." B.) "You may have a sore throat for 1 week." C.) "You are allowed to have hot tea or coffee." D.) "Decrease oral intake if increased swallowing occurs."
Answer: A.) "Gargle with a warm salt solution."
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 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."
Answer: A.) "The ET tube will maintain your airway while you're under anesthesia."
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states A.) "Do not smoke and avoid being around others who are smoking." B.) "It is fine to speak in a whisper. This does not strain your voice." C.) "Do not use a humidifier; it will make your problem worse." D.) "The 'tickle' in your throat will improve with cold liquids."
Answer; A.) "Do not smoke and avoid being around others who are smoking." Rationale: A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosol aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.
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
Answer; A.) An antiviral agent such as acyclovir
