Chapter 26

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? A. Assess the client for obstructive sleep apnea. B. Arrange a home sleep apnea test. C. Encourage the client to begin exercising. D. Schedule a polysomnography

A

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. What action would the nurse take next? A. Collect the nasal drainage on a piece of filter paper. B. Encourage the client to blow his or her nose. C. Perform a test focused on a neurologic examination. D. Palpate the nose, face, and neck.

A

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. What action would the nurse take first? A. Contact the primary health care provider and prepare for intubation. B. Administer prescribed albuterol nebulizer therapy. C. Place the client in high-Fowler position. D. Ask the client to perform deep-breathing exercises.

A

A nurse assesses a client who is 6 hours postsurgery for a nasal fracture and has nasal packing in place. What actions would the nurse take? (Select all that apply.) A. Observe for clear drainage. B. Assess for signs of bleeding. C. Watch the client for frequent swallowing. D. Ask the client to open his or her mouth. E. Administer a nasal steroid to decrease edema. F. Change the nasal packing.

A B C D

A nurse teaches a client who is being discharged after a jaw wiring for a mandibular fracture. Which statements would the nurse include in this patient's teaching? (Select all that apply.) A. "You will need to cut the wires if you start vomiting." B. "Eat six soft or liquid meals each day while recovering." C. "Use a Waterpik for dental hygiene until you can brush again. D. "Sleep in a semi-Fowler position after the surgery." E. "Gargle with mouthwash that contains hydrogen peroxide once a day."

A B C D

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) A. Hypertension B. Stroke C. Weight gain D. Diabetes E. Cognitive deficits F. Pulmonary disease

A B C D E F

A nurse assesses a client who is at risk for neck cancer. Which symptoms would the nurse assess for? (Select all that apply.) A. Oral mucosa is gray or dark brown B. Pain when drinking grapefruit juice C. Persistent weight gain over the past 2 months D. Oral lesions that are over 2 weeks old E. Changes in the patient's voice quality

A B D E

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for airway loss related to aspirated oral and nasopharyngeal secretions? (Select all that apply.) A. A 24 year old with a traumatic brain injury B. A 36 year old who fractured his left femur C. A 58 year old getting radiation therapy D. A 66 year old who is a quadriplegic E. An 80-year-old who is aphasic

A C D E

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) A. Stridor B. Nasal stuffiness C. Edema of the cheek D. Ecchymosis behind the ear E. Eye pain F. Swollen chin

A D

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How would the nurse respond? A. "I will consult the speech therapist to ensure you are swallowing properly." B. "This is normal after surgery. What types of food do you like to eat?" C. "I will ask the dietitian to change the consistency of the food in your diet." D. "Replacement of protein, calories, and water is very important after surgery."

B

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement would the nurse include in this patient's teaching? A. "Add peppermint oil to the humidifier to relax the airway." B. "Make sure you clean the humidifier to prevent infection." C. "Keep the humidifier filled with water at all times." D. "Use the humidifier when you sleep, even during daytime naps."

B

A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? A. Tilt the head back as far as possible when swallowing. B. Swallow twice while bearing down. C. Breathe slowly and deeply while swallowing. D. Keep the head very still and straight while swallowing.

B

A nurse teaches a client who has epistaxis and recently had his nasal packing removed. Which statements indicate that the client correctly understood the teaching? (Select all that apply.) A. "I will vigorously blow my nose multiple times each day." B. "Nasal saline sprays will help to prevent rebleeding." C. "I will wait at least 1 month before resuming weight lifting." D. "Ibuprofen will decrease nasal swelling and pain." E. "I will apply a small amount of petroleum jelly to my nares."

B C E

The nurse is teaching a client with obstructive sleep apnea (OSA) about the prescribed CPAP. What information does the nurse include? (Select all that apply.) A. Insurance will cover the cost if you wear it at least 4 hours a day. B. Once the delivery mask is adjusted, do not loosen the straps. C. The CPAP provides pressure that holds your upper airways open. D. You need to clean the mask at least once a week to prevent infection. E. The humidification increases the risk of fungal infections. F. Be patient when first using the system, it can be frustrating at first.

B C E F

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? A. A 26-year-old woman who is 8 months pregnant. B. A 42-year-old man with gastroesophageal reflux disease. C. A 55-year-old woman who is 50 lb (23 kg) overweight. D. A 73-year-old man with type 2 diabetes mellitus.

C

A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme dry mouth. What action by the nurse is most appropriate? A. Ask the client to gargle with mouthwash containing lidocaine. B. Administer IV fluid boluses every 2 hours. C. Explain that xerostomia may be a permanent side effect. D. Assess the client's neck for redness and swelling.

C

A nurse cares for a client who is scheduled for a total laryngectomy. What action would the nurse take prior to surgery? A. Assess airway patency, breathing, and circulation. B. Administer prescribed intravenous pain medication. C. Assist the client to choose a communication method. D. Ambulate the client in the hallway to assess gait.

C

A nurse cares for a client who has packing inserted for posterior nasal bleeding. What action would the nurse take first? A. Assess the client's pain level. B. Keep the client's head elevated. C. Teach the client about the causes of nasal bleeding. D. Assess the client's airway.

D

A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first? A. Facial pain B. Vital signs C. Bone displacement D. Airway patency

D

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? A. Client reports pain is controlled satisfactorily with analgesic regime. B. Client does not have foul odor to the breath or beefy red mucus membranes. C. Client is able to swallow own secretions without drooling. D. Client's vital signs are within normal parameters.

C