Chapter 22: Upper res. tract disorders
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 undergoes a laryngectomy to treat laryngeal cancer. What instruction should the nurse include in the teaching about the neck stoma?
"Keep the stoma moist."
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."
Which clinical manifestation of hemorrhage is related to carotid artery rupture?
Increased pulse rate
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
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
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.
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
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?
Rapid, deep respirations
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
Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?
Use enteral feedings after the procedure
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"
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.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
