NUR 125 PrepU Chapter 18: Management of Patients with Upper Respiratory Tract Disorders
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.
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
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
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
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.
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
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid
swimming.
Late symptoms of laryngeal cancer include which of the following. Select all that apply.
Dysphagia Dyspnea Persistent hoarseness
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
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?
Emotional support
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 herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
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
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
"Family members should continue to talk to the client."
Which assessment finding puts a client at increased risk for epistaxis?
Cocaine use
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.
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?
Amoxicillin
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
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
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
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
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
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
Another term for clergyman's sore throat is
chronic granular pharyngitis
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)
The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?
Provide the client with audiovisual materials about the surgery.
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:
Sleep with the head of bed elevated.
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
Stands behind the worker, who has hands across the neck
