NCA - Exam #3 - Chap 22 - PrepUs

b) Blom-Singer voice prosthesis

Which of the following methods most resembles normal speech following a total laryngectomy? a) Esophageal speech b) Blom-Singer voice prosthesis c) Lip speaking d) Electrolarynx held at neck

b) Disturbed body image

Which of the following nursing diagnoses best encompasses the anticipated psychosocial concerns of a client who is scheduled for a laryngectomy? a) Risk for chronic low self-esteem b) Disturbed body image c) Deficient knowledge d) Risk for infection

a) Drainage is <30 mL/day for 2 consecutive days.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? a) Drainage is <30 mL/day for 2 consecutive days. b) The stoma is healed, about 6 weeks after surgery. c) The patient is able to assist with his own suctioning. d) The surgical site is dry with encrustations.

b) "Do not smoke and avoid being around others who are smoking."

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states a) "It is fine to speak in a whisper. This does not strain your voice." b) "Do not smoke and avoid being around others who are smoking." c) "The 'tickle' in your throat will improve with cold liquids." d) "Do not use a humidifier; it will make your problem worse."

c) Report relief of pain to level 3 using a pain intensity scale of 1 to 10.

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) Use a pain intensity rating scale of 0 to 10. b) Take acetaminophen with codeine when pain is 5 or above. c) Report relief of pain to level 3 using a pain intensity scale of 1 to 10. d) Gargle with a warm saline solution frequently.

a) 2 to12 days.

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of a) 2 to12 days. b) 3 to 6 months. c) 0 to 3 months. d) 20 to 30 days.

b) Initial washing of hands after cleaning inner cannula.

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation? a) Use of non-sterile tissues to wipe secretions from the airway. b) Initial washing of hands after cleaning inner cannula. c) Wearing a loose-fitting cloth over the stoma. d) Client use of tweezers to remove encrustations.

a) Amoxicillin (Augmentin)

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)

a) ineffective airway clearance related to excess mucus production

The client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. The client is receiving humidified oxygen. A priority nursing diagnosis is: a) ineffective airway clearance related to excess mucus production b) ineffective breathing pattern related to inflammatory effects of surgery c) anxiety related to the effects of surgery and loss of voice d) impaired gas exchange related to ventilation-perfusion inequality

b) When the patient has less than 30 mL for 2 consecutive days

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed? a) When the patient states that there is discomfort and requests removal b) When the patient has less than 30 mL for 2 consecutive days c) In 1 week when the patient no longer has serous drainage d) When the drainage tube comes out

d) A face mask

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 rigid shell b) A nasal cannula c) A ventilator d) A face mask

a) "I was chewing ice chips all day long."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? a) "I was chewing ice chips all day long." b) "I smoke a pack of cigarettes a day." c) "I used my voice in excess over the weekend." d) "I have environmental allergies."

c) Swimming

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

d) Avoid sports activities for 6 weeks.

The nurse is providing discharge instructions to a patient following nasal surgery who has nasal packing. Which of the following discharge instructions would be most appropriate for the patient? a) Take aspirin for nasal discomfort. b) Decrease the amount of daily fluids. c) Administer normal saline nasal drops as ordered. d) Avoid sports activities for 6 weeks.

b) Alternative methods of communication

You are caring for a client who has just been told they have advanced laryngeal cancer and will have to have a total laryngectomy. You are doing preoperative teaching with this client. What do you know is a subject you should cover? a) Visiting hours b) Alternative methods of communication c) Pain before surgery d) Post operative nutrition

c) Edema of the upper airway

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) Plugged tracheostomy tube b) Infection c) Edema of the upper airway d) Post operative bleeding

a) Bleeding

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 talking c) Throat pain d) Difficulty swallowing

b) Nuchal rigidity

Stiffness of the neck or inability to bend the neck is referred to as which of the following? a) Dysphagia b) Nuchal rigidity c) Xerostomia d) Aphonia

b) Total laryngectomy

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? a) Laser surgery b) Total laryngectomy c) Radiation therapy d) Partial laryngectomy

c) Within 1 week.

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) Within 24 hours. b) In 2 to 3 weeks. c) Within 1 week. d) After 1 month.

d) It requires the insertion of a prosthesis into the trachea.

The nurse is instructing a client who is scheduled for a laryngectomy about methods of alaryngeal speech. Which of the following 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.

b) Gastroesophageal reflux disease (GERD)

A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following? a) Respiratory failure (RF) b) Gastroesophageal reflux disease (GERD) c) Congestive heart failure (CHF) d) Chronic obstructive pulmonary disease (COPD)

d) "Gargle with a warm salt solution."

A client is being discharged from an outpatient surgery center following a tonsillectomy. The nurse gives the following instructions: a) "Gargle vigorously to clean your throat." b) "You may have a sore throat for 1 week." c) "You are allowed to have hot tea or coffee." d) "Gargle with a warm salt solution."

d) Ineffective airway clearance related to excess mucus production

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) Deficient fluid volume related to increased fluid needs b) Acute pain related to upper airway irritation c) Deficient knowledge related to prevention of upper respiratory infections d) Ineffective airway clearance related to excess mucus production

a) Recommend guaifenesin (Mucinex). b) Teach the client about handwashing. d) Provide warm salt-water gargles. e) Administer oral ibuprofen (Motrin).

A client reports nasal congestion, sneezing, sore throat, and muscle aches. The nurse intervenes how? Select all answers that apply. a) Recommend guaifenesin (Mucinex). b) Teach the client about handwashing. c) Refer the client to a physician for antibiotic therapy. d) Provide warm salt-water gargles. e) Administer oral ibuprofen (Motrin).

a) "Family members should continue to talk to the client."

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? a) "Family members should continue to talk to the client." b) "Limit the amount of protein in the diet." c) "Clean the tracheostomy tube with alcohol and water." d) "Oral intake of fluids should be limited for 1 week only."

c) Avoid air travel.

A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information: a) Severe pain when palpating the sinuses is normal. b) Make sure to follow antibiotic therapy. c) Avoid air travel. d) Dehumidify the air in the home.

a) sit upright, leaning slightly forward.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: a) sit upright, leaning slightly forward. b) blow his nose and then put lateral pressure on his nose. c) lie supine with his neck extended. d) hold his nose while bending forward at the waist.

d) "You should rest, increase your fluids, and take Ibuprofen."

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) "Your symptoms should go away soon, just try to get some rest." b) "Have you tried a topic nasal decongestant; they work well." c) "Antibiotics will be prescribed, which will make you feel better." d) "You should rest, increase your fluids, and take Ibuprofen."

a) Ampicillin

A first-line antibiotic utilized in the treatment of acute sinusitis includes a) Ampicillin b) Cefzil c) Ceftin d) Augmentin

d) Administer one intramuscular injection of penicillin.

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) Provide the client with oral penicillin that will last for 5 days. c) Provide emphatic oral instructions for the client. d) Administer one intramuscular injection of penicillin.

a) Stands behind the worker, who has hands across the neck

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) Exerts pressure against the worker's abdomen c) Makes a fist with one hand with the thumb outside the fist d) Places both arms around the worker's waist

c) Hoarseness of more than 2 week's duration

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) Persistent ulceration b) Cervical lymph adenopathy c) Hoarseness of more than 2 week's duration d) Dysphasia

d) Group A, beta-hemolytic streptococcus

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis? a) Pseudomonas aeruginosa b) Gram-negative Klebsiella c) Staphylococcus aureus d) Group A, beta-hemolytic streptococcus

b) The nasal mucosa

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 buccal mucosa b) The nasal mucosa c) The frontal sinuses d) The tracheal mucosa

d) Group A, beta-hemolytic streptococci

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) Gram-negative Klebsiella d) Group A, beta-hemolytic streptococci

a) Mastoiditis d) Peritonsillar abscess e) Otitis media

A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.) a) Mastoiditis b) Pericarditis c) Encephalitis d) Peritonsillar abscess e) Otitis media

d) Amoxicillin-clavulanic acid (Augmentin)

A patient 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 patient about? a) Cefuroxime (Ceftin) b) Cephalexin (Keflex) c) Clarithromycin (Biaxin) d) Amoxicillin-clavulanic acid (Augmentin)

c) Partial laryngectomy

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? a) Total laryngectomy b) Supraglottic laryngectomy c) Partial laryngectomy d) Hemilaryngectomy

a) An antiviral agent such as acyclovir

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 antihistamine such as Benadryl c) An antibiotic such as amoxicillin d) An ointment such as bacitracin

d) Carotid hemorrhage

A patient has undergone a laryngectomy. The nurse notes evidence of wound breakdown. The nurse understands that the patient is at a high risk for developing which of the following? a) Dehydration b) Pneumonia c) Pulmonary embolism d) Carotid hemorrhage

c) Partial laryngectomy

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) Vocal cord stripping b) Cordectomy c) Partial laryngectomy d) Total laryngectomy

d) Enalapril (Vasotec)

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) Valsartan (Diovan) b) Metoprolol succinate (Toprol XL) c) Amlodipine (Norvasc) d) Enalapril (Vasotec)

c) laryngeal cancer is one of the most preventable types of cancer.

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) adenocarcinoma accounts for most cases of laryngeal cancer. b) inhaling polluted air isn't a risk factor for laryngeal cancer. c) laryngeal cancer is one of the most preventable types of cancer. d) laryngeal cancer occurs primarily in women.

b) Rapid, deep respirations

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) Increased blood pressure b) Rapid, deep respirations c) Decreased pulse rate d) Warm, moist skin

d) Hypercapnia

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

c) Viral infection

Most cases of acute pharyngitis are caused by which of the following? a) Bacterial infection b) Systemic infection c) Viral infection d) Fungal infection

d) Thick liquids that are easy to swallow.

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

d) a persistent cough or sore throat"

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) difficulty swallowing foods" b) a foul odor to your breath" c) trouble with your breathing" d) a persistent cough or sore throat"

d) Audible stridor without using a stethoscope

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated? a) Rhonchi in the bronchial region b) Diminished breath sounds throughout c) Crackles in the bases of the lungs d) Audible stridor without using a stethoscope

a) Laryngeal necrosis

The nurse is caring for a patient receiving radiation therapy for laryngeal cancer. A late complication of radiation therapy includes which of the following? a) Laryngeal necrosis b) Dysphasia c) Pain d) Xerostomia

c) Auscultate lung sounds.

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) Monitor heart rhythm. b) Obtain vital signs. c) Auscultate lung sounds. d) Assess capillary refill.

b) "You can use writing or a communication board to communicate."

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

c) Hoarseness for 2 weeks

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) Laryngitis following a cold c) Hoarseness for 2 weeks d) Epistaxis, twice last week

c) develop an alternative communication method.

When caring for a client who has just had a total laryngectomy, the nurse should plan to: a) encourage oral feedings as soon as possible. b) keep the client flat in bed. c) develop an alternative communication method. d) keep the tracheostomy cuff fully inflated.

d) Ensure mouth breathing

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) Provide a splint postoperatively c) Apply pressure to the convex portion of the nose d) Ensure mouth breathing

b) Check the clear fluid for glucose.

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) Check the clear fluid for glucose. c) Administer prescribed oral ibuprofen (Motrin). d) Apply an ice pack to the nose.

c) Blow the nose before applying medication into the nares.

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.

b) A feeling of swelling at the back of the throat

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) Discomfort when drinking cold liquids b) A feeling of swelling at the back of the throat c) Weight loss d) Headaches in the morning

a) Apply direct continuous pressure.

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis? a) Apply direct continuous pressure. b) Provide a nasal splint. c) Place the client in a semi-Fowler's position. d) Apply a moustache dressing.

b) Nuchal rigidity

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) Nuchal rigidity c) Mild headache d) Nausea

d) Prepare to administer subcutaneous epinephrine and corticosteroids.

A patient presents to the ED with a suspected allergic reaction. The patient is experiencing laryngeal edema causing obstruction and is demonstrating retractions in the neck during inspirations. Which of the following is the nurse's priority intervention? a) Apply 100% oxygen via a face mask. b) Prepare for immediate tracheostomy. c) Prepare for endotracheal intubation with mechanical ventilation. d) Prepare to administer subcutaneous epinephrine and corticosteroids.

a) A permanent tracheal stoma would be necessary.

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: a) A permanent tracheal stoma would be necessary. b) One vocal cord was removed along with a portion of the larynx. c) A portion of the vocal cord was removed. d) The voice was spared and a tracheostomy would be in place until the airway was established.

d) Affected voice sounds

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) Enlarged cervical nodes b) Dysphagia c) Burning of the throat when hot liquids are ingested d) Affected voice sounds

d) Use enteral feedings after the procedure

Which of the following interventions regarding nutrition is implemented for patients who have undergone laryngectomy? a) Season food to suit an increased sense of taste and smell b) Recommend the long-term use of zinc lozenges c) Offer plenty of thin liquids when intake resumes d) Use enteral feedings after the procedure

c) Ineffective airway clearance

Which of the following is the priority nursing diagnosis for the patient undergoing a laryngectomy? a) Anxiety and depression b) Impaired verbal communication c) Ineffective airway clearance d) Imbalanced nutrition: Less than body requirements

b) Airway patency

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? a) Pain level b) Airway patency c) Psychological status d) Level of consciousness

d) Noisy breathing

You are caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? a) Hardened secretions b) Incrusted mucous membranes c) Erosion of the trachea d) Noisy breathing

a) Injury to the laryngeal nerve c) Infection e) Aspiration

You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply. a) Injury to the laryngeal nerve b) Penetration of the anterior tracheal wall c) Infection d) Absence of secretions e) Aspiration

d) "Research has shown that heredity contributes to having laryngeal cancer."

Your client has just been diagnosed with laryngeal cancer. The client asks you what causes laryngeal cancer. What would be your best response? a) "A carcinogen associated with laryngeal cancer is allergies." b) "A carcinogen associated with laryngeal cancer is carbon monoxide." c) "Research has shown that habitual resting of the voice contributes to laryngeal cancer." d) "Research has shown that heredity contributes to having laryngeal cancer."