CH 46 - ORAL/ESOPH DISORDERS

One way for the nurse to confirm placement of a nasogastric tube is to test the pH of the tube aspirate. The nurse knows that tube placement in the lungs is indicated with a pH of:

6

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. The nurse plans to include all the following in the 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. Assess respiratory status every 4 hours and prn. The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. 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.

A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is:

Approximately 80 to 120 mL. Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.

A patient has undergone a radical neck dissection. His skin graft site is pale. This indicates which of the following conditions?

Arterial thrombosis A pale graft indicates arterial thrombosis. A cyanotic, cool graft indicates possible necrosis. A purple graft indicates venous congestion.

A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. The first activity of the nurse is to:

Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment

The client is postoperative following a graft reconstruction of the neck. It is most important for the nurse to

Assess the graft for color and temperature. The nurse may do all these activities related to the neck wound and dressing. Airway, breathing, circulation (ABCs) take priority. Assessing the graft for color and temperature addresses circulation.

A client with anorexia complains of constipation. Which of the following nursing measures would be most effective in helping the client reduce constipation?

Assist client to increase dietary fiber

The nurse is creating a plan of care for a patient who is not able to tolerate brushing his teeth. The nurse includes in the plan of care which of the following mouth irrigations?

Baking soda and water When a patient is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp of baking soda to 8 oz of warm water, half-strength hydrogen peroxide, or normal saline solution.

Which of the following is the term for a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre

Brock Nichols, a 4-year-old preschooler, is being seen in the ED where you practice nursing. His mother reports that Brock has been vomiting for 3 days and is unable to "keep anything down." What poses the greatest danger to Brock?

Dehydration

Cancer of the esophagus is most often diagnosed by which of the following?

Esophagogastroduodenoscopy (EGD) with biopsy and brushings

Amanda Ford, a 53-year-old actress, is being seen by a physician in your oncology group for a diagnosis of oral cancer. She is in the initial stages of diagnosis and is frightened about the side effects of treatment and subsequent prognosis. She also has many questions regarding the type of cancer she has been diagnosed with and asks where oral cancer typically occurs. What is your response?

Floor of the mouth

Postoperatively, a patient with a radical neck dissection should be placed in which position?

Fowler's

A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon?

Gastroesophageal reflux disease

A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?

Gastroesophageal reflux disease

Myrtle Gass, a 79-year-old resident at the long-term care facility where you practice nursing, has developed anorexia and has lost her interest in eating. During the care team meeting with her family and physician, concerns are voiced over her lack of appetite. After discussion, what is an intervention that might successfully increase Mrs. Gass's caloric intake?

High-calorie diet of her favorite foods Persistent anorexia may require various approaches, such as a high-calorie diet, high-calorie supplemental feedings, tube feedings, and total parenteral nutrition (TPN). High-calorie supplemental feedings may be required to increase caloric intake.

Which of the following is one of the first clinical manifestations of esophageal cancer

Increasing difficulty is swallowing

Which of the following is one of the first clinical manifestations of esophageal cancer?

Increasing difficulty is swallowing

Which of the following would be an intervention for a patient with a chemical burn to the esophagus?

Insertion of nasogastric (NG) tube An NG tube may be inserted by the medical team. Vomiting and gastric lavage are avoided to prevent further exposure of the esophagus to the caustic agent. The patient is given nothing by mouth, and IV fluids are administered.

Which of the following are functions of saliva? Select all that apply.

Lubrication Protection against harmful bacteria Digestion

Tyrone Freeman is a 49-year-old male being treated for GERD at the gastroenterology office where you work. During his visit, he states that his reflux is much improved, but now, he is having diarrhea. In addition to his prescribed treatment for GERD, he has been taking an antacid. Which of the following components of an antacid might be causing his diarrhea?

Magnesium The magnesium component may tend to cause diarrhea in some clients. Magnesium can cause diarrhea in some clients.

Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?

Metoclopramide (Reglan) Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

Which of the following is the most common symptom of gastrointestinal (GI) problems in general?

Nausea

A patient has been taking a 10-day course of antibiotics for pneumonia. The patient has been having white patches that look like milk curds in the mouth. What treatment will the nurse educate the patient about?

Nystatin (Mycostatin) Candidiasis is a fungal infection that results in a cheesy white plaque in the mouth that looks like milk curds. It commonly occurs in antibiotic therapy. Antifungal medications such as nystatin (Mycostatin), amphotericin B, clotrimazole, or ketoconazole may be prescribed.

A patient complains about an inflamed salivary gland below his right ear. The nurse documents probable inflammation of which gland?

Parotid The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.

The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. It is most important for the nurse to

Place the client in the Fowler's position.

A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):

Protrusion of the upper stomach into the lower portion of the thorax.

A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which of the following strategies can the nurse employ to assist this client?

Provide the client with an irrigating solution of baking soda and warm water. If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended.

A client with peptic ulcer disease complains of sharp mid-epigastric pain. Which assessment finding is most important to the care of this client?

Rigid abdomen Sudden sharp mid-epigastric pain and abdominal rigidity are symptoms of perforation and needs immediate intervention. Pain relieved with food only to return an hour later is typical of peptic ulcer disease. Explosive diarrhea without further symptoms bears attention but not immediate.

Which of the following terms is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis

An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?

Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).

A patient comes to the clinic complaining of a sore throat. When assessing the patient, the nurse observes a reddened ulcerated lesion on the lip. The patient tells the nurse that it has been there for a couple of weeks but it does not hurt. What should the nurse consult with the physician about testing for?

Syphilis The primary lesion of syphilis is a chancre, which is a reddened circumscribed lesion that ulcerates and becomes crusted.

James Jaeger, a 59-year-old carpenter, is being seen by a physician in your oncology group with a diagnosis of oral cancer. During your client education, Mr. Jaeger tells you that he is upset that he didn't recognize any early signs or symptoms of his disease. What do you tell Mr. Jaeger about the early stage of his cancer?

There are usually no symptoms

A client has a new order for metoclorpramide (Reglan). The nurse knows that this medication should not be used long term and only in cases where all other options have been exhausted. This is because this medication has the potential for extrapyramidal side effects. Extrapyramidal side effects include which of the following?

Uncontrolled rhythmic movements of the face or limbs Metoclorpramide is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.

Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?

Vagus

Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?

Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.

A nurse is doing her initial assessment on a client who had gastric bypass surgery the previous day. Which of the following would she expect to see when observing the client's nasogastric tube drainage?

Yellow-green secretions

When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. Aphthous stomatitis is best described as:

a canker sore of the oral soft tissues.

The most common symptom of esophageal disease is

dysphagia.

A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by

Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after as esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.

Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.

Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease?

Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. The patient should be instructed to avoid the listed foods and food components. The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. The patient is instructed to eat a low-fat diet.

The nurse is caring for a patient with a history of bulimia. The patient complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which of the following conditions?

Boerhaave syndrome Boerhaave syndrome, a spontaneous rupture of the esophagus after forceful vomiting (may occur after eating a large meal), is characterized by retrosternal pain, dysphagia, infection, fever, and severe hypotension. Halitosis (bad breath) is a symptom of pharyngoesophageal pulsion diverticulum, also known as Zenker's diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

Which of the following is an inaccurate clinical manifestation associated with hemorrhage?

Bradycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.

A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. The nurse instructs the client to

Brush and floss daily. 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.

Which of the following is the primary symptom of achalasia?

Difficulty swallowing

The nurse is caring for an older adult who complains of xerostomia. The nurse evaluates for use of which of the following medications?

Diuretics Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the patient's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.

The most common symptom of esophageal disease is which of the following?

Dysphagia

An elderly client seeks medical attention for a vague complaint of difficulty swallowing. Which of the following assessment findings is most significant as related to this symptom?

Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.

A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition?

Give high-protein, semiliquid foods A major goal for a client with esophageal cancer is adequate or improved nutrition and eventually stable weight. Because he has difficulty in swallowing, the nurse should ensure that the client receives soft foods or high-calorie, high-protein, semiliquid foods to get improved nutrition. Providing oral liquids alone will not provide improved nutrition. Using a straw leads to bloating and should be avoided. Providing liquid supplements are used in between meals, not as meals. Encouraging small, frequent meals will give improved nutrition to a client who does not have any difficulty in swallowing.

A patient who is HIV positive comes to the clinic and is experiencing white patches with rough hairlike projections. The nurse observes the lesions on the lateral border of the tongue. What abnormality of the mouth does the nurse determine these lesions are?

Hairy leukoplakia Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough hairlike projections occur, typically found on lateral border of the tongue.

The nurse is caring for a patient during the postoperative period following radical neck dissection. Which of the following should be reported to the physician?

High epigastric pain and/or discomfort The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not require reporting to the physician.

A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:

Make a notation on the call light system that the client cannot speak.

A client with a history of peptic ulcer disease is admitted for hematemesis associated with gastric bleeding. Which is the most appropriate action of the nurse?

Prepare for nasogastric irrigations. Hemorrhage with peptic ulcer disease is initially handled through cold saline lavage via nasogastric tube. Increasing the IV rate is not a nursing measure. Administering oxygen is not indicated unless the client is experiencing respiratory difficulties. While having hematemesis, the head of the bed would remain elevated to avoid risk for aspiration.

Which of the following terms refers to the symptom of gastroesophageal reflux disease (GERD) which is characterized by a burning sensation in the esophagus?

Pyrosis 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.

A client with peptic ulcer disease is scheduled for a partial gastrectomy and vagotomy. The nurse understands the surgery will accomplish which of the following physiologic effects?

Remove source of acid secretion. In a vagotomy, the vagus nerve is severed to decrease stimulation of gastric acid secretion. A delay in gastric emptying can be experienced after a vagotomy but is not the intended outcome. A portion of the stomach is removed to reduce acid by removing the source of acid secretion. Clients may experience dumping syndrome as a result of this surgery, which can result in malabsorption and anemia. Pernicious anemia can be an adverse effect of this surgery.

A client is preparing for discharge to home, following a partial gastrectomy and vagotomy. Which is the best rationale for the client being taught to lie down for 30 minutes after each meal?

Slows gastric emptying Dumping syndrome is a common complication following subtotal gastrectomy. To avoid the rapid emptying of stomach contents, resting after meals can be helpful. Promoting rest after a major surgery is helpful in recovery but not the reason for resting after meals. Following this type of surgery, clients will have a need for vitamin B12 supplementation due to absence of production of intrinsic factor in the stomach. Resting does not increase absorption of B12 or remove tension on suture line.

A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?

Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.

A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?

The client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration.

The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department for chest pain. The client was diagnosed as having gastroesophageal reflux disease. The nurse notes in the client's record that the client is taking carbidopa/levodopa (Sinemet). The nurse questions the physician's order for

metoclopramide The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa, which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.

To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?

"Avoid coffee and alcoholic beverages."

A nurse practitioner, who is treating a patient with GERD, knows that responsiveness to this drug classification is validation of the disease. The drug classification is:

Proton pump inhibitors. Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.

Regarding oral cancer, the nurse provides health teaching to inform the patient that

many oral cancers produce no symptoms in the early stages.

The term for a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis is

chancre

An elderly client states, "I don't understand why I have so many caries in my teeth." The nurse assesses the following as placing the client at risk:

Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.

The nurse working in the recovery room is caring for a patient who had a radical neck dissection. The nurse notices that the patient has a coarse, high-pitched sound on inspiration. Which of the following is the appropriate intervention by the nurse?

Notifying the physician The presence of stridor, a coarse, high-pitched sound on inspiration, in the immediate postoperative period following radical neck dissection indicates obstruction of the airway and requires that the nurse report it immediately to the physician

Paul Cavanagh, a 63-year-old retired teacher, had oral cancer and had extensive surgery to excise the malignancy. Although his surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to Mr. Cavanagh and his family?

Time to mourn, accept, and adjust to the loss The first time family members or clients see the effects of surgery, the experience usually is traumatic. The nurse needs to promote effective coping and therapeutic grieving at this time. Responses may range from crying or extreme sadness and avoiding contact with others to refusing to talk about the surgery or changes in appearance. Allowing the client time to mourn, accept, and adjust to losses is essential.