PrepU 39: Management of Patients With Oral and Esophageal Disorders

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

"Avoid coffee and alcoholic beverages" To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.

A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?

"Eliminating bothersome foods will help" Irritating foods such as spices, caffeine, and alcohol should be avoided because these will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.

An adolescent client with multiple dental caries is discussing diet with the nurse. What client statement identifies a risk factor for dental caries?

"I drink a can of carbonated soda at lunch everyday" The client's statement of drinking a carbonated soda with refined sugar at lunch every day puts the client at risk for dental caries. The other statements are measures to prevent dental caries, including brushing teeth after meals, flossing daily, and having regular dental visits.

A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?

Achalasia Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.

While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's 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. Based the anticipated orders by the health care provider, 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.

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. Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.

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

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 diverticulum. A periapical abscess (an abscessed tooth) is characterized by dull, gnawing continuous pain, cellulitis, and edema and mobility of the involved tooth.

When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention?

Elevate the head of the bed 90 degrees during meals The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.

A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document?

Hairy leukoplakia Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.

The nurse is caring for a client receiving chemotherapy. For which mouth conditions associated with HIV infection should the nurse assess? Select all that apply.

Kaposi sarcoma stomatitis candidiasis Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion that is associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy, as well as HIV infection. Erythroplakia is caused by a nonspecific inflammation. Candidiasis is caused by fungus and is the most common fungal infection associated with HIV.

Which mouth condition is most associated with HIV infection?

Kaposi sarcoma Kaposi sarcoma appears first on the oral mucosa as a red, purple, or blue lesion. Of the conditions listed, it is the most associated with HIV infection. Stomatitis is associated with chemotherapy and radiation therapy. Krythoplakia is caused by a nonspecific inflammation. Candidiasis is caused by fungus.

The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply.

Oral hygiene Follow-up dental appointment Follow-up medical appointment Use of humidification Discharge teaching for a client after oral surgery includes oral hygiene, follow-up dental and medical appointments, and the use of humidification to keep secretions moist.

Which of the following is the most common type of diverticulum?

Zenker's diverticulum The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).

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. How is aphthous stomatitis best described by the nurse?

a chancre core of the oral soft tissues Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.

A patient has been NPO for two days anticipating surgery which has been repeatedly delayed. In addition to risks of nutritional and fluid deficits, the nurse determines that this patient is at the greatest risk for:

altered oral mucus membranes Not drinking anything by mouth can result in drying of the oral mucous membranes, compromising their integrity. Being NPO is unrelated to physical injury or ineffective social interaction. Confusion is unlikely to result from the client's NPO status.

The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings?

aphthous stomatitis Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.

A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first?

apply pressure to the bleeding site The first action for the nurse is to apply pressure to the bleeding site. The nurse will need to obtain assistance, elevate the head of the bed, and notify the surgeon, but client care is most important initially.

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

approximately 80-120 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 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. What would be the first activity performed by the nurse?

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.

A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?

assess the graft for color and temperature Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.

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.

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?

sialadenitis Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.

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

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

Which clinical manifestation is not 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. What instruction will the nurse give to the client?

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.

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

chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus are white papules at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.

Which is an accurate statement regarding cancer of the esophagus?

chronic irritation of the esophagus is a known risk factor In the United States, cancer of the esophagus has been associated with the ingestion of alcohol and the use of tobacco. In the United States, carcinoma of the esophagus occurs more than three times more often in men as in women. It is seen more frequently in African Americans than in Caucasian Americans. It usually occurs in the fifth decade of life.

Which is the primary symptom of achalasia?

difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.

The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?

dysphagia Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).

The most common symptom of esophageal disease is

dysphagia This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.

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.

An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?

exhibiting hemoglobin A1C at 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.

A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about?

extrapyramidal Metoclopramide (Reglan) 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.

A client is in the initial stages of oral cancer diagnosis and is frightened about the side effects of treatment and subsequent prognosis. The client has many questions regarding this type of cancer and asks where oral cancer typically occurs. What is the nurse's response?

floor of the mouth Malignant growths can be found anywhere in the oral cavity, but cancers usually occur on the lips, sides of the tongue, or floor of the mouth.

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

fowler The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding 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 need to be reported to the physician.

A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?

increasing difficulty in swallowing The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.

A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as

ineffective airway clearance related to obstruction by mucus All the nursing diagnoses are appropriate for a client who has a radical neck dissection. According to Maslow's hierarchy of needs, physiological needs take priority. Under physiological needs, airway, breathing, circulation (ABCs) take highest priority. Thus, ineffective airway clearance is the highest priority nursing diagnosis.

The nurse is planning care for a client with painful oral lesions. Which food should be included in the client's diet?

jell-o The nurse should include Jell-O in the client's diet; spicy, hot, and/or hard foods or beverages (pretzels, hot tea, chili) should be avoided to reduce pain and discomfort in the client with painful oral lesions.

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

lithotripsy Lithotripsy uses shock waves to disintegrate stones. It may be used instead of surgical extraction for parotid stones and smaller submandibular stones. Radiation, chemotherapy, and biopsy do not use shock waves to disintegrate a stone.

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

lubrication protection against harmful bacteria digestion The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.

A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to?

maintaining a patent airway Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.

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 patient cannot speak The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.

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) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.

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

nystatin 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 reports an inflamed salivary gland below the 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.

A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms 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.

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 It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.

Which of the following refers to a bacterial or viral infection of the salivary glands?

sialadenitis Sialadenitis refers to the bacterial or viral infection of the salivary glands. Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands. Mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting children, is an inflammation of a salivary gland, usually the parotid. Stomatitis involves inflammation and breakdown of the oral mucosa; it is often a side effect of chemotherapy or radiation therapy.

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

sialolithiasis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.

Select the assessment finding that the nurse should immediately report, post radical neck dissection.

stridor Stridor is the presence of coarse, high-pitched sounds on inspiration. The nurse would auscultate frequently over the trachea. This finding must be immediately reported because it indicates airway obstruction.

A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education?

surgical removal of the diverticulum Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. A low-residue diet will not stop the progression of the disease. Chemotherapy and radiation therapy will not target the specific site of the Zenker's diverticulum.

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 the 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. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.

A client who had oral cancer has had extensive surgery to excise the malignancy. Although surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to this client and 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.

A client has a new order for metoclopramide. What extrapyramidal side effect should the nurse assess for in the client?

uncontrolled rhythmic movements in the face or limbs Metoclopramide 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 for uncontrolled rhythmic movements of the face or limbs. Metoclopramide side effects are headache, confusion, and drowsiness. Anxiety, hyperactivity, and a dry mouth are not common side effects.

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

vagus Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.

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

weakness, diaphoresis, diarrhea 9 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.