NUR 212 Chap 53

A client is having a temporary tracheostomy placed during surgery for oral cancer. What action by the nurse is best to relieve anxiety? a. Agree on a postoperative communication method. b. Explain that staff will answer the call light promptly. c. Give the client a Magic Slate to write on postoperatively. d. Reassure the client that you will take care of all of his or her needs.

ANS: A Before surgery that interrupts the client's ability to communicate, the nurse, client, and family (if possible) agree upon a method of communication in the postoperative period. The client may or may not prefer a slate and may not be able to communicate in writing. Reassuring the client and telling him or her you will take care of all of his or her needs does not help the client be an active participant in care. Ensuring that the staff will answer the call light promptly will not guarantee this will occur.

A client is prescribed cetuximab (Erbitux) for oral cancer and asks the nurse how it works. What response by the nurse is best? a. "It blocks epidermal growth factor." b. "It cuts off the tumor's blood supply." c. "It prevents tumor extension." d. "It targets rapidly dividing cells."

ANS: A Cetuximab (Erbitux) targets and blocks the epidermal growth factor, which contributes to the growth of oral cancers. The other explanations are not correct.

The nurse reads a client's chart and sees that the health care provider assessed mucosal erythroplasia. What should the nurse understand that this means for the client? a. Early sign of oral cancer b. Fungal mouth infection c. Inflammation of the gums d. Obvious oral tumor

ANS: A Mucosal erythroplasia is the earliest sign of oral cancer. It is not a fungal infection, inflammation of the gums, or an obvious tumor.

The nurse is caring for a client who has just received a diagnosis of advanced oral cancer and has learned that a glossectomy with jaw resection will have to be scheduled. The client states to the nurse, "I would rather die than have half of my face removed. My life is over." Which is the best description of the client's response to the diagnosis? a. Refusal of any more treatment b. Grief over the diagnosis c. Acceptance of the diagnosis d. Denial about the diagnosis

ANS: B The client is grieving the loss of his health and present appearance. Because the client has just learned of the diagnosis and treatment, the client is reacting in a negative way. This behavior demonstrates grief, not necessarily refusal of treatment, nor denial or acceptance of the diagnosis.

A nurse is caring for four clients. After receiving the hand-off report, which client should the nurse see first? a. Client having a radial neck dissection tomorrow who is asking questions b. Client who had a tracheostomy 4 hours ago and needs frequent suctioning c. Client who is 1 day postoperative for an oral tumor resection who is reporting pain d. Client waiting for discharge instructions after a small tumor resection

ANS: B The client who needs frequent suctioning should be seen first to ensure that his or her airway is patent. The client waiting for pain medication should be seen next. The nurse may need to call the surgeon to see the client who is asking questions. The client waiting for discharge instructions can be seen last.

The spouse of a client has just completed tracheostomy care for the first time, with minimal assistance from the nurse. Which statement offers the most constructive feedback from the nurse? a. "I see that you had a tough time, but you will do better with practice." b. "You were able to clean the inner cannula well. Now, let's change the ties again." c. "You seem to have had a tough time because it was your first attempt." d. "You seem to understand what I said. Is there anything else I can help you with?"

ANS: B The statement that provides the most positive feedback concerns what the client's spouse did well and identifies a skill that needs more practice. The other responses by the nurse give negative overtones to the teaching environment and do not empower the spouse.

The nurse is assessing a client during a routine physical examination. Which statement made by the client concerning the risk of oral cancer indicates that further teaching is needed? a. "I will brush my teeth and floss regularly." b. "I will begin a smoking cessation program." c. "I can still use chewing tobacco since I stopped smoking." d. "I will limit my intake of alcoholic beverages."

ANS: C Tobacco in any form increases the risk of oral cancer. The client should be educated to eliminate all tobacco products. The other statements concerning brushing the teeth, flossing, smoking cessation, and decreasing alcohol intake are healthy choices to maintain good oral health.

The nurse is caring for a client who will be taking nystatin (Mycostatin) for treatment of oral candidiasis. Which instructions does the nurse provide for the client before administering the medication? a. "Let the tablet dissolve slowly in your mouth." b. "Take the medicine with a snack or a light meal." c. "Swallow the pills whole, followed by a full glass of water." d. "Swish the liquid around your mouth before swallowing it."

ANS: D Mycostatin (nystatin) is a liquid medication that should be swished around the mouth for a minute before swallowing. The other responses do not reflect accurate administration of nystatin.

A client has a large oral tumor. What assessment by the nurse takes priority? a. Airway b. Breathing c. Circulation d. Nutrition

ANS: A Airway always takes priority. Airway must be assessed first and any problems resolved if present.

The nurse is performing oral health screenings at a local community center. Which clients are at higher risk for developing oral cancer? (Select all that apply.) a. Female who has taken oral contraceptives for the last 4 years b. Adult client with a history of alcoholism c. Adult client who regularly eats spicy foods d. Middle-aged male who smokes a pipe e. Adult client who goes to a tanning salon weekly f. Client who frequently chews gum

ANS: B, D, E Alcoholism (particularly with poor nutritional status), tobacco use, and exposure to the sun or tanning salons are all risk factors for the development of oral cancer. Oral contraceptives, spicy foods, and chewing gum are not high-risk activities for oral cancer.

The nurse is caring for a client with stomatitis. Which items reported during the history of the client may contribute to the reoccurrence of this condition? (Select all that apply.) a. Drinking two glasses of wine nightly b. Smoking three cigarettes each day c. Vitamin A deficiency d. Drinking four cups of coffee daily e. Fruits and nuts as the mainstay of the diet f. Vitamin C deficiency

ANS: A, B, D, E Stomatitis can result from irritants such as alcohol, smoking, caffeine, fruits, and nuts. Deficiencies in vitamin A or C do not seem to have any relationship to the development of stomatitis, but deficiency of vitamin B, folate, and iron has a relationship to stomatitis development.

A nurse studying cancer knows that job-related risks for developing oral cancer include which occupations? (Select all that apply.) a. Coal miner b. Electrician c. Metal worker d. Plumber e. Textile worker

ANS: A, C, D, E The occupations of coal mining, metal working, plumbing, and textile work produce exposure to polycyclic aromatic hydrocarbons (PAHs), which are known carcinogens. Electricians do not have this risk.

The nurse is caring for a client who has just completed treatment for basal cell carcinoma on the lower lip. The client says to the nurse, "Cigarettes are ruining my life. I'll do anything to quit smoking." Which is the nurse's best response? a. "Here is some information about smoking cessation programs in the area. Let's discuss the options." b. "Here are some pamphlets that show the financial benefits of quitting smoking." c. "If you quit smoking, your risk for developing cancer again will decrease dramatically." d. "Your chest x-ray is still clear, so you could prevent permanent lung damage if you quit smoking now."

ANS: A The client has indicated a readiness to quit smoking; therefore, the nurse should help the client choose the best course of action by taking time to discuss the options. The other responses provide good rationales for why quitting smoking would be a positive outcome, but no help is being offered in preparing a plan to quit.

The nurse is caring for a client who just had a radical jaw and neck resection. The nurse is developing a teaching plan for the client and spouse about care after discharge from the hospital. Which is an effective teaching objective for this client and spouse? a. The client's spouse will be able to change the client's tracheostomy ties correctly after three teaching sessions. b. The client and spouse will verbalize the signs of readiness for oral feedings following placement of the tracheostomy. c. The client's spouse will correctly administer the client's tube feedings twice daily. d. The client and spouse will understand incision care and the importance of infection prevention.

ANS: A The objective is action oriented, specific, achievable, and measurable. The other responses are not as clear and measurable.

The nurse is caring for a client who has just undergone a partial glossectomy and partial mandibulectomy for oral cancer. Which is the highest priority for this client? a. Maintenance of the airway b. Ability to communicate c. Adequate body image d. Pain management

ANS: A The priority problem for a client with oral cancer surgery is possible ineffective airway clearance. Airway obstruction can result from the presence of edema or secretions and could be life threatening. Communication is another problem postoperatively because of the tracheostomy tube, but a communication process should be established preoperatively. Emotional support should be given to help the client adjust to the new body image, and pain management should be maintained with IV medications.

A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is the priority? a. Delegate oral care every 4 hours. b. Monitor and record the client's intake. c. Place the client in a high-Fowler's position. d. Remove the inner cannula for cleaning.

ANS: C To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The inner cannula may or may not need to be cleaned, and the tracheostomy may or may not have a disposable cannula.

The nurse is caring for a client with sialadenitis. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying warm compresses b. Massaging salivary glands c. Offering fluids every hour d. Providing lemon-glycerin swabs e. Reminding the client to avoid speaking

ANS: A, C The UAP can apply warm compresses and offer fluids. Massaging salivary glands can be done, but not by the UAP. Lemon-glycerin swabs are drying and should not be used. Speaking has no effect on this condition.

The nurse is caring for a client with stomatitis. Which statement does the nurse include in teaching about oral care for this client? a. "Rinse your mouth out twice a day with mouthwash." b. "Clean your mouth frequently during the day with a gentle foam sponge." c. "Use lemon-glycerin swabs to clean your mouth after meals and at bedtime." d. "Suck on ice cubes to minimize the discomfort."

ANS: B During painful, acute episodes of stomatitis, gentle mouth care using a gauze sponge dipped in warm normal saline or normal saline plus sodium bicarbonate is most appropriate. Commercial mouthwashes containing alcohol, acidic foods such as lemon-glycerin swabs, and techniques that may cause bleeding such as sucking on ice cubes should be avoided.

The nurse is caring for a client who has just undergone surgery for oral cancer. What advice does the nurse give the client to assist in maintaining the airway? a. "Limit your fluids to 3 cups of water a day." b. "Take deep breaths, hold, then cough to mobilize any secretions." c. "Lying flat in bed will be more comfortable for breathing." d. "Usually suctioning is not needed after oral surgery."

ANS: B Maintaining an airway after oral surgery is a priority. The client must be taught to deep breathe and mobilize the secretions by coughing effectively. The other responses are incorrect. Fluids should be increased, a semi-Fowler's or high Fowler's position should be maintained, and the client should be taught how to suction the oral cavity.

The nurse is caring for a client who will be undergoing a radical jaw and throat resection for oral cancer. Which statement by the client indicates that further teaching is needed? a. "I will have a temporary tracheostomy placed in my neck to help me breathe." b. "I will not be able to get out of bed for 3 days after surgery." c. "The doctor will put in a feeding tube for nutrition until I can swallow and eat." d. "My speech may be slurred for a long time after the surgery."

ANS: B Mobility should not be extensively limited. The client should not be on bedrest for 3 days. A temporary tracheostomy will be inserted to maintain a patent airway postoperatively. A nasogastric tube may be needed until oral nutrition can begin. Slurred speech is a common outcome if extensive resection has taken place and nerve damage has occurred.

A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist? a. Client who has poor oral hygiene practices b. Client who smokes and drinks daily c. Client who tans for an upcoming vacation d. Client who occasionally uses illicit drugs

ANS: B Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers.

A nurse assesses a client's oral cavity and observes the condition depicted in the photo below: What action by the nurse is best? a. Ask about the client's human immunodeficiency virus (HIV) status. b. Assess the client for dysphagia. c. Listen to the client's lung sounds. d. Refer the client to an oncologist.

ANS: B This client has oral candidiasis. If the infection extends down the pharynx, the client could have difficulty swallowing. Therefore, the nurse should assess the client for dysphagia. HIV status may or may not be related but is not the priority. Listening to the lungs is unrelated. Since oral candidiasis is an infectious condition, referral to an oncologist is not needed.

A student nurse is providing care to an older client with stomatitis and dysphagia. What action by the student nurse requires the registered nurse to intervene? a. Assisting the client to perform oral care every 2 hours b. Preparing to administer a viscous lidocaine gargle c. Reminding the client not to swallow nystatin (Mycostatin) d. Teaching the client to use a soft-bristled toothbrush

ANS: B Viscous lidocaine gargles or mouthwashes are sometimes prescribed for clients with stomatitis and pain. However, the numbing effect can lead to choking or mouth burns from hot food. This client already has difficulty swallowing, so this medication is not appropriate. Therefore, the nurse should intervene when the student prepares to administer this preparation. The other options are correct actions.

The nurse is assessing a client with a salivary gland tumor for facial nerve involvement. Which movements does the nurse ask the client to perform? (Select all that apply.) a. Open the mouth wide. b. Raise the eyebrows. c. Smile or frown. d. Pucker the lips. e. Blow the nose. f. Puff out the cheeks.

ANS: B, C, D, F With salivary gland tumors, close proximity to the facial nerve can cause damage to the nerve, which can be assessed by looking at the symmetric performance of certain movements such as raising the eyebrows, smiling, frowning, puckering the lips, and puffing out the cheeks. Opening the mouth widely or blowing the nose would not indicate any facial nerve involvement.

The nurse is caring for a female client who has just undergone excision of a parotid gland tumor. The client tells the nurse that she is experiencing facial weakness on the operative side. Which is the nurse's best response? a. "You may be experiencing a slight stroke, and I will notify the doctor." b. "This is a temporary condition that will resolve once radiation treatment is begun." c. "You are experiencing weakness because the facial nerve was irritated during the surgery." d. "You probably have a pinched nerve after lying on the operating room table for so long."

ANS: C Cranial nerve V involvement is a possible outcome of this type of surgery. The client presents with facial weakness and possibly with loss of sensation to the affected side. The other choices regarding facial weakness following this type of surgery are not accurate.

The nurse is caring for a client who has undergone a radical jaw and neck resection. The client tells the nurse that the area feels very swollen and painful. Which is the best intervention for the nurse to make this client more comfortable? a. Frequently suction the client's mouth and airway. b. Apply warm moist compresses to the area. c. Elevate the head of the client's bed to semi-Fowler's. d. Administer ibuprofen (Motrin) 600 mg every 6 hours around the clock.

ANS: C Elevating the head of the bed will help to reduce edema by using gravity. Ibuprofen can affect blood clotting, leading to bleeding from the incisions. Intravenous morphine is a better choice than ibuprofen. Suctioning should be completed only when necessary because this will be uncomfortable. Moist compresses are used with salivary gland inflammation, not with postoperative radical jaw and neck resection.

The nurse is leading a teaching session about methods to decrease the risk of mouth cancer. Which client statement indicates that the nurse was successful in teaching the information? a. "I will chew tobacco rather than smoke it." b. "I will use sugar rather than artificial sweeteners." c. "I will regularly use a lip balm that contains sunscreen." d. "I will use a tanning salon rather than sunbathing at the beach."

ANS: C Lip balms that contain sunscreen can help prevent the development of oral cancer. The rest of the client choices can promote cancer, such as chewing tobacco and tanning. Using sugar rather than artificial sweeteners is not applicable to the risk of mouth cancer.

The nurse is caring for a client who will be going home after a radical jaw and neck resection. The client's spouse will be the primary caregiver at home and will need to care for the client's feeding tube and tracheostomy. Which skill is the highest priority for the nurse to teach the client's spouse before discharge from the hospital? a. Monitoring the incision lines for infection or leakage of saliva b. Assessing the client for readiness to resume oral feedings c. Cleaning the tracheostomy and suctioning as needed d. Administering tube feedings and cleaning the feeding tube site

ANS: C Maintaining a patent airway is the highest priority for this client and spouse. The other responses are next in importance because they reflect needed knowledge regarding infection control and knowledge of proper technique for nutritional support of the client.

The nurse is caring for a client who is being discharged following surgery for oral cancer. Which sign is the client instructed to watch for that indicates possible metastasis of the cancer? a. Fragile gums that bleed easily b. White patches on the tongue and the back of the throat c. Painful ulcerated lesions on the gums or inside of the cheek d. Small hard lumps on the side of the neck or under the chin

ANS: D Cervical lymph nodes that become hardened, enlarged, and fixed in position are indications of metastatic disease. An older adult or a client with a dry mouth may develop fragile gums that bleed easily. White patches on the tongue and the back of throat could be leukoplakia—precancerous lesions that are normally benign. Stomatitis or inflammation of the oral cavity can lead to fragile gums, white patches (candidiasis), and painful open sores throughout the oral cavity, but these conditions are not cancerous.

The nurse is caring for a client who is receiving radiation therapy for treatment of oral cancer. The client reports a constant dry mouth. Which is the nurse's best response? a. "Massage the area just over the lower jaw twice a day." b. "Use lemon and glycerin swabs to clean your mouth and help keep it moist." c. "Suck on lemon slices to help increase saliva production." d. "Rinse your mouth out often with warm saline or sodium bicarbonate solution."

ANS: D Clients should avoid agents that can irritate the oral mucosa and should keep their mouth moist with frequent rinses of warm saline or sodium bicarbonate solution. Massage is recommended only for acute sialadenitis—inflammation of a salivary gland. Lemon slices and lemon and glycerin swabs are acidic and can further dry the mucosa, causing a burning sensation. The use of lemon slices after radiation therapy is discontinued may promote saliva production.

A female client hospitalized for an unrelated problem has a large pearly-white lesion on her lip, to which she continues to apply lipstick that she will not remove for inspection. The client refuses to discuss the lesion with the nurse or health care provider. What action by the nurse is best? a. Ask the client why her appearance is so important. b. Ignore the lesion since the client will not discuss it. c. Inform the client that early-stage cancer is curable. d. Work with the client to establish a trusting relationship.

ANS: D Clients with oral cancers often have body image difficulties due to the location of the tumor or the results of surgical treatment. This client appears to be using denial to cope with this problem. The nurse should work to establish a helping-trusting relationship in hopes that the client will be amenable to future discussions about the lesion. Asking "why" questions often puts people on the defensive and should be avoided. Ignoring the lesion is not being an advocate for the client. Education is important, but right now the client is in denial, so this information will not seem relevant to her.

The nurse is caring for a client who has just received a diagnosis of advanced oral cancer that will require extensive surgery. Which statement by the client indicates that the diagnosis is accepted? a. "The biopsy test results will be confirmed again next week." b. "Of all the bad things to happen to me, now I have cancer on top of it all." c. "If I can live long enough to see my son get married, everything will be alright." d. "I don't like it, but I have cancer and that's the way it is."

ANS: D The client has accepted the diagnosis. He is not happy about it but has acknowledged the reality of the situation. The other responses indicate denial, anger, or bargaining responses to the diagnosis.

The nurse is caring for a client who just had a radical jaw and neck resection for oral cancer. The nurse has just completed teaching for the spouse and client about tracheostomy care. Which notation in the client's chart is the most accurate documentation of the teaching that occurred? a. "The client and spouse were instructed regarding management of mucous plugs and thick secretions." b. "Information about home oxygen therapy and equipment was provided for the client and spouse." c. "The client and spouse were shown how to suction the tracheostomy and change the ties." d. "Correct suctioning procedure was demonstrated, and the client's spouse verbalized two instances when suctioning needs to occur."

ANS: D The documentation should include teaching actions, as well as the spouse's response to the instructions. The other choices do not indicate the response by the client and spouse to the teaching. A return demonstration would be beneficial.