NSG 245- Ch 22 Management Upper Respiratory Tract Disorders
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?
Ineffective airway clearance Explanation: All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine the highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.
The nurse is providing patient teaching to a patient diagnosed with acute rhinosinusitis. For what possible complication should the nurse teach the patient to seek immediate follow-up?
Periorbital edema Patient teaching is an important aspect of nursing care for the patient with acute rhinosinusitis. The nurse instructs the patient about symptoms of complications that require immediate follow-up. Referral to a physician is indicated if periorbital edema and severe pain on palpation occur
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?
Swimming 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.
A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?
Apply ice and keep the patients head elevated.
The perioperative nurse has admitted a patient who has just underwent a tonsillectomy. The nurses postoperative assessment should prioritize which of the following potential complications of this surgery?
Hemorrhage Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage
he nurse is teaching a patient with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this patient about preventing possible drug interactions?
Read drug labels carefully before taking OTC medications
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
Ineffective airway clearance related to airway alterations
The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?
"You can use writing or a communication board to communicate." Explanation: If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.
A client exhibits a sudden and complete loss of voice and is coughing. The nurse states
"Do not smoke and avoid being around others who are smoking."
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?
"I was chewing ice chips all day long." Allergies, smoking, and excessive use of the voice causing straining are frequent causes of laryngitis
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?
20 mL or less The pleural space, located between the visceral and parietal pleura, normally contains 20 mL of fluid or less. The fluid helps lubricate the visceral and parietal pleura.
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?
Apply direct continuous pressure.
The nurse is caring for a patient who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?
Assessment of swallowing ability
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?
Avoid sports activities for 6 weeks.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?
Drainage is <30 mL/day for 2 consecutive days. Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.
The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?
Epistaxis
A mother calls the clinic asking for a prescription for Amoxicillin for her 2-year-old son who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
I'll certainly inform the doctor, but if it is a cold, antibiotics wont be used because they do not affect the virus.
The nurse is doing discharge teaching in the ED with a patient who had a nosebleed. What should the nurse include in the discharge teaching of this patient?
In case of recurrence, apply direct pressure for 15 minutes.
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
Keep a complete suction setup at the bedside
A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?
Laryngeal cancer Explanation: Persistent hoarseness (longer than 2 weeks) is usually the earliest symptom.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing 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 45-year-old obese man arrives in a clinic with complaints of daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of what health problem?
Obstructive sleep apnea
The nurse is explaining the safe and effective administration of nasal spray to a patient with seasonal allergies. What information is most important to include in this teaching?
Overuse of nasal spray may cause rebound congestion.
A nurse practitioner has provided care for three different patients with chronic pharyngitis over the past several months. Which patients are at greatest risk for developing chronic pharyngitis?
Patients who are habitual users of alcohol and tobacco
he nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient? Select all that apply.
Protein level Albumin level Glucose level
The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a patient who is postoperative day 1 following total laryngectomy. How should the nurse respond to this development?
Rapidly assess the patient and notify the surgeon about the patients bleeding.
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
Report relief of pain to level 3 using a pain intensity scale of 0 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 nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
Seek medical help if he experiences inability to swallow
A patient has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to what complication?
Sinus infections
The nurse is providing care for a patient who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
The patients airway patency
A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response?
This cancer usually does not spread to distant sites in the body
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy 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 nurse is providing patient teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season?
Wash her hands frequently. Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. Antibiotics are not prescribed for a cold.
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 feeling of swelling at the back of the 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 persistent cough or sore throat" Explanation: Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath.
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is
amoxicillin-clavulanic acid.
The nurse is conducting a presurgical interview for a patient with laryngeal cancer. The patient states that he drinks approximately six to eight shots of vodka per day. It is imperative that the nurse inform the surgical team so the patient can be assessed for what?
Delirium tremens
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 Later, the client notes a sensation of swelling or a lump in the throat, followed by dysphagia and pain when talking. Hoarseness is not indicative of pharyngeal cancer; laryngeal polyps; or cancer of the tonsils.
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?
"Do you smoke cigarettes, cigars, or a pipe?"
A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?
"Gargle with a warm salt solution." Explanation: A warm saline solution will help with removal of thick mucus and halitosis. It will be a gentle gargle, because a vigorous gargle may cause bleeding. A sore throat may be present for 3 to 5 days. Hot foods should be avoided.
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
10 seconds with 5 episodes/hour. Explanation: OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump?
100 mL/hr
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days. HSV-1 is transmitted primarily by direct contact with infected secretions.
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 face mask Explanation: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
The home care nurse is assessing the home environment of a patient who will be discharged from the hospital shortly after his laryngectomy. The nurse should inform the patient that he may need to arrange for the installation of which system in his home?
A humidification system
A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment?
A liquid or soft diet A liquid or soft diet is provided during the acute stage of the disease, depending on the patients appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
A permanent tracheal stoma would be necessary. 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 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?
Administer one intramuscular injection of penicillin. Explanation: If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.
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 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. However, affected voice sounds are not always early signs of subglottic or supraglottic cancer. The patient may report a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.
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?
Alternative methods of communication Explanation: Discuss alternative methods of communication and identify which method the client prefers. Visiting hours, pain and post operative nutrition are not generally covered at this point in preoperative teaching.
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?
Amoxicillin Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
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?
An antiviral agent such as acyclovir 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.
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
Apply an ice pack. Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client 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 client 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 client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
Apply an ice pack. Explanation: Following a nasal fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client 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 client 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.
An adolescent client sustains a fractured nose during a high school basketball game. Which action will the school nurse take first to help this client?
Apply ice with the client in a seated position. Explanation: Nasal fracture is the most common facial fracture and the most common fracture in the body. The signs and symptoms of a nasal fracture are pain, bleeding from the nose externally and internally into the pharynx, swelling of the soft tissues adjacent to the nose, periorbital ecchymosis, nasal obstruction, and deformity. The client's nose may have an asymmetric appearance that may not be obvious until the edema subsides. Immediately after the fracture, ice is applied and the client is instructed to keep the head elevated. The client should then be taken for emergency care when rolled gauze pads may be used to stop bleeding. Resetting of the nose may not occur for 3 to 7 days after the injury because of the edema
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. 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.
The nurse is performing the health interview of a patient with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the patient about her current medication regimen. Which medication would put the patient at a higher risk for recurrent epistaxis?
Beconase Beconase should be avoided in patients with recurrent epistaxis, glaucoma, and cataracts. Sinustop Pro and Afrin are pseudoephedrine and do not have a side effect of epistaxis. Singulair is a bronchodilator and does not have epistaxis as a side effect.
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
Blow the nose before applying medication into the nares. The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.
A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.
Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks. Explanation: Ice or cold compresses are applied four to six times a day, for several days, until the swelling is decreased. Packing is inserted to control bleeding. It would not be used to reshape the nose.
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
Check the clear fluid for glucose. Explanation: The client's signs and symptoms are consistent with a fracture of the nose. Clear fluid draining from either nostril suggests leakage of cerebrospinal fluid. This can be checked by assessing for glucose, which is in cerebrospinal fluid. This finding is important to identify, because infection can be transmitted through the opening in the cribriform plate. Other options, such as applying an ice pack to the nose and administering ibuprofen, are appropriate interventions but not most important for this client. Reassuring the client that the nose is not fractured is premature until all assessments are completed.
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?
Chronic granular Explanation: 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.
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
Develop an alternate method of communication. The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.
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?
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?
Edema of the upper airway
The nurse is creating a plan of car for a patient diagnosed with acute laryngitis. What intervention should be included in the patients plan of care?
Encourage the patient to limit speech whenever possible. Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool steam or an aerosol. Fluid intake should be increased. Warm cloths on the throat will not help relieve the symptoms of acute laryngitis.
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
Epistaxis Explanation: Common side effects of budesonide (Rhinocort) include epistaxis, pharyngitis, cough, nasal irritation, and bronchospasm.
As a clinic nurse, you are caring for a patient who has been prescribed an antibiotic for tonsillitis and has been instructed to take the antibiotic for 10 days. When you do a follow-up call with this patient, you are informed that the patient is feeling better and is stopping the medication after taking it for 4 days. What information should you provide to this patient?
Finish all the antibiotics to eliminate the organism completely
A patients total laryngectomy has created a need for alaryngeal speech which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the patient when teaching him about this process?
Fitting for a voice prosthesis In patients receiving transesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis (Blom-Singer) is fitted over the puncture site.
The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?
Fracture of the cribriform Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum.
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
Gastroesophageal reflux disease (GERD)
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
Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask whether the client has a medical history of GERD. Laryngitis is common in older adults and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.
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?
Group A, beta-hemolytic streptococci Viral infection causes most cases of acute pharyngitis. Responsible viruses include the adenovirus, influenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial infection accounts for the remainder of cases. Ten percent of adults with pharyngitis have group A beta-hemolytic streptococcus (GABHS), which is commonly referred to as group A streptococcus (GAS) or streptococcal pharyngitis.
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?
Group A, beta-hemolytic streptococcus The adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.
The nurse is caring for a patient whose recent unexplained weight loss and history of smoking have prompted diagnostic testing for cancer. What symptom is most closely associated with the early stages of laryngeal cancer?
Hoarseness Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer.
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 Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
The nurse is caring for a patient in the ED for epistaxis. What information should the nurse include in patient discharge teaching as a way to prevent epistaxis?
Humidify the indoor environment. Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose bleeding, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated.
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).
A patient visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the patient to perform which of the following?
Increase fluid intake. For a patient diagnosed with acute sinusitis, the nurse should instruct the patient that hot packs, increasing fluid intake, and elevating the head of the bed can promote drainage. Applying a mustard poultice will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.
Which is the priority nursing diagnosis for a client undergoing a laryngectomy?
Ineffective airway clearance Explanation: The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but the question is asking for the priority nursing diagnosis for this patient. The priority is to identify any issues related to impaired airway.
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 All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.
Select the nursing diagnosis that would warrant immediate health care provider notification.
Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation
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. 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.
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. Explanation: 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.
The campus nurse at a university is assessing a 21-year-old student who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the student to tilt her head forward and the nurse applies pressure to the nose, but the students nose continues to bleed. Which intervention should the nurse next implement?
Insert a tampon in the affected nare
The occupational health nurse is obtaining a patient history during a pre-employment physical. During the history, the patient states that he has hereditary angioedema. The nurse should identify what implication of this health condition?
It can cause life-threatening airway obstruction Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema
The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication?
It inhibits the release of histamine and other chemicals. Cromolyn (Nasalcrom) inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.
The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?
It requires the insertion of a prosthesis into the trachea. TEP requires a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom-Singer device. An artificial larynx is a throat vibrator held against the neck that projects sound into the mouth. With esophageal speech, the client forms words with the lips. Esophageal speech causes the voice quality to be lower pitched and gruff sounding.
The nurse is caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?
Laryngeal necrosis Explanation: Late complications of radiation therapy include laryngeal necrosis, edema, and fibrosis. Pain, xerostomia, and dysphasia are not late complications of radiation therapy.
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for
Nuchal rigidity 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 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?
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?
Partial laryngectomy Explanation: In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply.
Polycythemia Loud snoring Insomnia Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, , polycythemia, and enuresis.
The nurse is performing preoperative teaching with a patient who has cancer of the larynx. After completing patient teaching, what would be most important for the nurse to do?
Provide the patient with audiovisual materials about the surgery.
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about
Saline lavages to the nares Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated.
A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about
Saline lavages to the nares Explanation: Saline lavages are used for acute rhinosinusitis and relieve symptoms, reduce inflammation, clear nasal passages of stagnant mucus, and reduce the development of opportunistic infections. Other methods that promote drainage of the sinuses are humidifying the air, not dehumidifying it, and warm compresses, not cold compresses, to the sinus cavities. Because this infection is viral, antibiotics are not indicated.
A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patients midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?
Silver nitrate application If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated. General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
Sudden restlessness Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
A nursing student is discussing a patient with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for patients with viral pharyngitis?
Symptom management is the main focus of medical and nursing care.
The nurse is caring for a patient who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the patient asks, Will this chronic infection hurt my new kidney? What should the nurse know about chronic rhinosinusitis in patients who have had a transplant?
Taking immunosuppressive drugs can contribute to chronic rhinosinusitis. URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
Telling the client to sit upright with the head tilted forward Explanation: Hemorrhage or massive bleeding from the nose is called epistaxis. Initial interventions include having the client sit upright with the head tilted forward to prevent swallowing and aspiration of blood. Tilting the head back will encourage the client to swallow and possibly aspirate blood. Pressure is applied to the soft outer portion of the nose against the midline septum, not the upper and hard portion of the nose. Pressure is also applied continuously for 5 to 10 minutes.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose. Explanation: Because cerebrospinal fluid (CSF) contains glucose, testing nasal drainage for glucose helps determine whether it's CSF. The nurse should look for a halo sign only if the drainage is blood tinged. A client with a suspected CSF leakage shouldn't blow his nose; doing so could increase the risk of injury. The nurse should contact the physician after completing the assessment.
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?
The nasal mucosa Explanation: The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinates may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.
A patient states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor?
The virus is shed for 2 days prior to the emergence of symptoms.
The nurse is caring for a patient with a severe nosebleed. The physician inserts a nasal sponge and tells the patient it may have to remain in place up to 6 days before it is removed. The nurse should identify that this patient is at increased risk for what?
Toxic shock syndrome A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 5 or 6 days if necessary to control bleeding. Antibiotics may be prescribed because of the risk of iatrogenic sinusitis and toxic shock syndrome.
The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?
Tracheoesophageal puncture Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.
Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?
Use enteral feedings after the procedure Explanation: Enteral feedings are used 10 to 14 days after a laryngectomy to avoid irritation to the sutures and reduce the risk of aspiration. When oral intake resumes, the nurse offers small amounts of thick liquids. Following a laryngectomy, the client may experience anorexia related to a diminished sense of taste and smell. Excess zinc can impair the immune system and lower the levels of high-density lipoproteins ("good" cholesterol). Therefore, long-term or ongoing use of zinc lozenges to prevent a cold is not recommended.
It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?
Use of warm saline gargles or throat irrigations can relieve symptoms. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105F to 110F (40.6C to 43.3C). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis.
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?
When the patient has less than 30 mL for 2 consecutive days
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
bleeding 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.
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
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:
laryngeal cancer is one of the most preventable types of cancer. Explanation: Laryngeal cancer is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of laryngeal cancer.
The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options. The nurse monitors the client for purulent nasal drainage , a finding indicative of rhinosinusitis , a noted complication of nasogastric tubes.
purulent nasal drainage; rhinosinusitis
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
sinus infection. Explanation: Clients with nasotracheal and nasogastric tubes in place are at risk for developing sinus infections. Thus, accurate assessment of clients with these tubes is critical. Removal of the nasotracheal or nasogastric tube as soon as the client's condition permits allows the sinuses to drain, possibly avoiding septic complications. Severe epistaxis is not a complication of nasotracheal placement. Subperiosteal abscess and orbital cellulitis are complications of chronic rhinosinusitis.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
