N 403 Ch 45 PrepU
The nurse is reviewing the chart of a client with swallowing problems. Which factors would raise suspicion that the client has cancer of the esophagus? Select all that apply. Smoking history of 20 years Male gender Previous treatment for gastroesophageal reflux disease Caucasian race Age 72 years
Correct response: - Smoking history of 20 years - Male gender - Previous treatment for gastroesophageal reflux disease Explanation: In the United States, carcinoma of the esophagus occurs more than three times as often in men as in women. It is seen more frequently in African Americans than in Caucasians and usually occurs in the fifth or sixth decade of life. Cancer of the esophagus has been associated with ingestion of alcohol and the use of tobacco. There is an apparent association between GERD and adenocarcinoma of the esophagus.
Which of the following interventions would be most appropriate for a client with a hiatal hernia and nursing diagnosis of acute pain related to reflux of gastric secretions? - Encourage the client to eat frequent, small, well-balanced meals. - Inform the client to remain upright for at least 2 hours after meals. - Instruct the client to avoid alcohol or tobacco products. - Instruct the client to eat slowly and chew the food thoroughly.
Correct response: Inform the client to remain upright for at least 2 hours after meals. Explanation: Because the client is showing signs of pain related to the pressure and the reflux of gastric secretions, it is essential to inform him or her to remain upright for at least 2 hours after meals because an upright position helps prevent reflux. Encouraging the client to eat frequent, small, well-balanced meals, to avoid alcohol and tobacco products, and to eat slowly and chew foods thoroughly would be appropriate for a nursing diagnosis of imbalanced nutrition, less than body requirements.
A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition? - Possible necrosis - Arterial thrombosis - Venous congestion - Infection
Correct response: Arterial thrombosis Explanation: A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer? - Herpes simplex 1 - Actinic cheilitis - Chancre - Erythroplakia
Correct response: Actinic cheilitis Explanation: Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of the horny layer of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed clients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Erythroplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as - Impaired tissue integrity related to surgical intervention - Imbalanced nutrition: less than body requirements, related to treatment - Risk for infection related to surgical intervention - Ineffective airway clearance related to obstruction by mucus
Correct response: Ineffective airway clearance related to obstruction by mucus Explanation: All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.
Which term describes an inflammation of the salivary glands? - Parotitis - Sialadenitis - Stomatitis - Pyosis
Correct response: Sialadenitis Explanation: Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
A client with oral cancer reports dryness of the mouth. What is the nurse's best response? - State, "This is a normal consequence of oral cancer." - Provide a humidifier for the client to use while sleeping. - Ensure that the client maintains a fluid intake of 2000 mL per day. - Allow the client to continue with his or her usual diet.
Correct response: Provide a humidifier for the client to use while sleeping. Explanation: Dryness of the mouth (xerostomia) is a frequent sequeala of oral cancer. While explaining this to the client provides information, it does nothing to help solve the problem. The nurse should encourage this client to increase intake of fluids to 2000 to 3000 mL per day. Providing a humidifier will assist in moisturizing the oral cavity. The client needs to be instructed to avoid dry, bulking, and irritating foods and fluids.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland? - Sialolithiasis - Parotitis - Sialadenitis - Stomatitis
Correct response: Sialolithiasis Explanation: Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.
The nurse instructs the client with gastroesophageal reflux disease (GERD) regarding dietary measures. Which action by the client demonstrates that the client has understood the recommended dietary changes? - Eliminating spicy foods. - Avoiding chocolate and coffee. - Eliminating cucumbers and other foods with seeds. - Avoiding steamed foods.
Correct response: Avoiding chocolate and coffee. Explanation: Chocolate, tea, cola, and caffeine lower esophageal sphincter pressure, thereby increasing reflux. Clients do not need to eliminate spicy foods unless such foods bother them. Foods with seeds are restricted in diverticulosis. Steamed foods are encouraged to retain vitamins and decrease fat intake.
A nurse is performing an assessment for a client who presents to the clinic with an erythemic, fissuring lip lesion with white hyperkeratosis. What does the nurse suspect that these findings are characteristic of? - Actinic cheilitis - Human papillomavirus lesion - Frey syndrome - Sialadenitis
Correct response: Actinic cheilitis Explanation: Actinic cheilitis is an irritation of the lips associated with scaling, crusting, fissure, and overgrowth of a white, horny layer of epidermis (hyperkeratosis). Human papillomavirus lesions appear as flat lesions, small cauliflower-like bumps, or tiny stem-like protrusions. Frey syndrome is damage to the parotid glands after surgery resulting in saliva disturbances. Sialadenitis is an infection associated with pain, tenderness, redness, and gradual, localized swelling affecting the salivary gland.
While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply. - Administer medication for report of pain. - Insert an intravenous (IV) catheter for administration of IV fluids. - Maintain nothing by mouth status. - Induce vomiting to remove the base solution from the stomach. - Assess respiratory status every 4 hours and prn.
Correct response: Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Assess respiratory status every 4 hours and prn. Explanation: The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.
The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings? - Aphthous stomatitis - Kaposi's sarcoma - Chancre - Hairy leukoplakia
Correct response: Aphthous stomatitis Explanation: Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. - maintaining an upright position following meals - avoiding foods that intensify symptoms - sleeping in a supine position - ensuring intake of food and fluids 2 to 3 hours before bedtime
Correct response: maintaining an upright position following meals avoiding foods that intensify symptoms Explanation: Conservative measures used in the treatment of GERD are maintaining an upright position following meals, avoiding foods that intensify symptoms, elevating the head of the bed when sleeping, and avoiding the intake of food and fluids 2 to 3 hours before bedtime.
A client experienced surgical resection of a tumor of the esophagus. After recovery from the anesthesia, what will the nurse include in the postoperative care plans? Select all that apply. - Assess lung sounds every 4 hours and prn. - Replace the nasogastric tube if the tube becomes dislodged. - Monitor drainage in the closed chest drainage system. - Verify rhythm on the cardiac monitoring system. - Maintain the client in a side-lying position.
Correct response: Assess lung sounds every 4 hours and prn. Monitor drainage in the closed chest drainage system. Verify rhythm on the cardiac monitoring system. Explanation: Following recovery from anesthesia for a surgical resection of an esophageal tumor, the client is placed in the Fowler's position. A common postoperative complication is aspiration pneumonia. The nurse assesses for this complication by assessing lung sounds. The nurse monitors the drainage in the closed chest drainage system. Because of irritation of the vagus nerve, the nurse assesses for the complication of atrial fibrillation. The nurse does not replace the nasogastric tube if it becomes dislodged.
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client? - Use a hard-bristled toothbrush. - Rinse with an alcohol-based solution. - Brush and floss daily. - Continue with the usual diet.
Correct response: Brush and floss daily. Explanation: The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett's esophagus and has been admitted to a medical unit. The nurse is writing a care plan for this patient. What information is essential to include? - He will need to undergo an upper endoscopy every 6 months to detect malignant changes. - Liver enzymes must be checked regularly as H2 receptor antagonists may cause hepatic damage. - Small amounts of blood are likely to be present in his stools and should not cause concern. - Antacids may be discontinued when symptoms of heartburn subside
Correct response: He will need to undergo an upper endoscopy every 6 months to detect malignant changes. Explanation: In the patient with Barrett's esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. To facilitate early detection of malignant cells, upper endoscopies may be performed every 6 to 12 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or which are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.
A group of students is reviewing information about oral cancers in preparation for an examination. The students demonstrate a need for additional review when they identify which of the following as a risk factor? - Pipe smoking - Excess alcohol use - Prolonged exposure to sun - History of GERD
Correct response: History of GERD Explanation: Development of oral cancers is linked with smoking, chewing tobacco, and drinking alcohol in excess. Lip cancer is associated with pipe smoking and prolonged exposure to wind and sun. A history of GERD is associated with the development of esophageal cancer.
Which mouth condition is most associated with HIV infection? - Kaposi sarcoma - Stomatitis - Krythoplakia - Candidiasis
Correct response: Kaposi sarcoma Explanation: Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion. Of the conditions listed, it is the most associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy. Krythoplakia is caused by a nonspecific inflammation. Candidiasis is caused by fungus.
The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply. - Oral hygiene - Follow-up dental appointment - Follow-up medical appointment - Use of humidification
Correct response: Oral hygiene Follow-up dental appointment Follow-up medical appointment Use of humidification Explanation: Discharge teaching for a client after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.
The nurse is preparing to assess the donor site of a client who underwent a myocutaneous flap after a radical neck dissection. The nurse prepares to assess the most commonly used muscle for this surgery. Which muscle should the nurse assess? - Trapezius - Biceps - Pectoralis major - Sternomastoid
Correct response: Pectoralis major Explanation: The most common donor site for a myocutaneous flap after radical neck dissection is the pectoralis major muscle, so the nurse should prepare to assess this site unless a different donor site is documented on the client's chart.
Tube feedings are advised for a client who is recovering from oral surgery. The nurse manages the tube feedings to minimize the risk of aspiration. Which measures should the nurse include in the care plan to reduce the risk of aspiration? Select all that apply. - Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. - Check tube placement and gastric residual prior to feedings. - Administer 15 to 30 mL of water before and after medications and feedings. - Change the tube feeding container and tubing.
Correct response: Place client in semi-Fowler's position during and 30 to 60 minutes after an intermittent feeding. Check tube placement and gastric residual prior to feedings. Explanation: Proper positioning prevents regurgitation. Checking tube placement and gastric residual prior to feedings is another important measure because it prevents improper infusion and vomiting.
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? - Pyrosis - Dyspepsia - Dysphagia - Odynophagia
Correct response: Pyrosis Explanation: Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? - a low-fat diet - elevation of upper body on pillows - pantoprazole - metoclopramide
Correct response: metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.
The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is - shoulder drop. - neck distension. - venous engorgement. - clavicle fracture.
Correct response: shoulder drop. Explanation: The nurse should include shoulder drop as an associated complication of radical neck dissection. Another associated complication is poor cosmesis, which is a visible depression in the neck. Clavicle fracture, venous engorgement, and neck distension are not complications associated with radical neck dissection.