Ch. 20 Caring for Clients with Upper Respiratory Disorders

The nurse is caring for a client experiencing laryngeal trauma. Upon assessment, swelling and bruising is noted to the neck. Which breath sound is anticipated?

Audible stridor without using a stethoscope Explanation: The nurse anticipates hearing audible stridor without needing a stethoscope due to the neck swelling narrowing the airway. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the bases of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction and not indicative of laryngeal swelling.

A client with acute viral rhinosinusitis is being seen in a clinic. The nurse is providing discharge instructions and includes the following information:

Avoid air travel. Explanation: Information that the nurse should include for a client with acute viral rhinosinusitis is to avoid air travel. Other nursing interventions include referring the client to a physician if severe pain occurs when palpating the sinuses and humidifying the air in the home to promote drainage. Antibiotic therapy is not indicated for a viral infection.

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to

Blow the nose before applying medication into the nares. Explanation: The nurse instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.

A 76-year-old man presents to the ED complaining of "laryngitis." The triage nurse should ask if the patient has a past medical history that includes which of the following?

Gastroesophageal reflux disease (GERD) Explanation: The nurse should ask if the patient has a past medical history of GERD. Laryngitis in the older adults is common and may be secondary to GERD. Older adults are more likely to have impaired esophageal peristalsis and a weaker esophageal sphincter. COPD, CHF, and RF are not associated with laryngitis in the older adult.

A client undergoes a laryngectomy to treat laryngeal cancer. When teaching the client how to care for the neck stoma, the nurse should include which instruction?

"Keep the stoma moist." Explanation: The nurse should instruct the client to keep the stoma moist, such as by applying a thin layer of petroleum jelly around the edges, because a dry stoma may become irritated. The nurse should recommend placing a stoma bib over the stoma to filter and warm air before it enters the stoma. The client should begin performing stoma care without assistance as soon as possible to gain independence in self-care activities.

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation?

Initial washing of hands after cleaning inner cannula. Explanation: The client should wash the hands before any care of the surgical site, particularly cleansing of the inner cannula. The other activities are appropriate outcomes for a client following laryngectomy.

The nurse is assessing a patient in the clinic, and upon physical assessment the patient demonstrates displacement of the sternum. This would be documented as which of the following conditions?

Pigeon chest Explanation: Pigeon chest may occur with rickets, Marfan's syndrome, or severe kyphoscoliosis. A barrel chest is seen in patients with emphysema and occurs as a result of over-inflation of the lungs. A funnel chest occurs when there is a depression in the lower portion of the sternum. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine.

The nurse is caring for a geriatric client brought to the emergency department after being found by her children feeling poorly with an elevated temperature. Laboratory tests confirm influenza type A, a respiratory virus. Which medical treatment would the nurse anticipate in the discharge instructions? Select all that apply.

Rest Increased fluids Saline gargles Antitussives Explanation: Influenza type A is the most common cause of the flu initiated by a respiratory virus. Common discharge instructions include rest, increased fluids to thin respiratory secretions, saline gargles to help prevent a throat infection such a strep throat, and antitussives if the client is coughing. Antibiotics are not used with a virus unless a bacterial infection subsequently develops. Antiemetics are used for nausea and vomiting not commonly associated with a common respiratory virus.

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?

Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. A harsh cough and rhonchi in the lung fields is common with the presence of mucous secretions.

The nurse initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, "Elevate the head of the bed 45°." This assists in meeting which nursing goal?

The client will have decreased edema. Explanation: Elevating the head of the bed 45° when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase the blood supply.

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 Explanation: The nurse inspects the nasal mucosa for abnormal findings such as increased redness, swelling, exudate, and nasal polyps, which may develop in chronic rhinitis. The mucosa of the nasal turbinate's may also be swollen (boggy) and pale bluish-gray. The nurse palpates the frontal and maxillary sinuses for tenderness, which suggests inflammation, and then inspects the throat by having the patient open the mouth wide and take a deep breath.

The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?

Administer an over-the-counter decongestant. Explanation: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opens the nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.

The nurse is assessing a patient who smokes 2 packs of cigarettes per day and has a strong family history of cancer. What early sign of cancer of the larynx does the nurse look for in this patient?

Affected voice sounds Explanation: Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not always early signs of subglottic or supraglottic cancer, however. The patient may complain of a persistent cough or sore throat and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms include dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath.

You are an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factors would you be sure to include in your workshop? Select all that apply.

Alcohol Tobacco Industrial pollutants

You are mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would you respond? Select all that apply.

Aspiration Infection Injury to the laryngeal nerve Explanation: The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.

Another term for clergyman's sore throat is

Chronic granular pharyngitis. Explanation: In clergyman's sore throat, the pharynx is characterized by numerous swollen lymph follicles. Aphonia refers to the inability to use one's voice. Atrophic pharyngitis is characterized by a membrane that is thin, white, glistening, and at times wrinkled. Hypertrophic pharyngitis is characterized by general thickening and congestion of the pharyngeal mucous membrane.

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

Drainage is <30 mL/day for 2 consecutive days. Explanation: Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to:

Eliminate alcohol ingestion. Explanation: The client's symptoms are consistent with obstructive sleep apnea. Initial treatment includes avoidance of alcohol and hypnotic medications. Clients are told to not sleep on their backs. Administration of nasal oxygen may help with hypoxemia but has little effect on the frequency of apnea.

A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?

Enalapril (Vasotec) Explanation: Use of ACE inhibitors, such as enalapril (Vasotec), is a risk factor for laryngeal obstruction resulting from edema of the throat as a result of a side effect of the drug.

A patient diagnosed 2 weeks ago with acute pharyngitis comes to the clinic stating that the sore throat got better for a couple of days and is now back along with an earache. What complications should the nurse be aware of related to acute pharyngitis? (Select all that apply.)

Mastoiditis Otitis media Peritonsillar abscess Explanation: Uncomplicated viral infections usually subside promptly, within 3 to 10 days after onset. However, pharyngitis caused by more virulent bacteria, such as GAS, is a more severe illness. If left untreated, the complications can be severe and life threatening. Complications include rhinosinusitis, otitis media, peritonsillar abscess, mastoiditis, and cervical adenitis. In rare cases, the infection may lead to bacteremia, pneumonia, meningitis, rheumatic fever, and nephritis.

The nurse is caring for a patient admitted with a diagnosis of bacterial pharyngitis. The nurse anticipates the patient will be ordered which of the following medications?

Penicillin Explanation: Treatment of choice for bacterial pharyngitis is penicillin. Penicillin V potassium taken for 5 days is the regimen of choice. Traditionally, penicillin was administered as a single injection; however, oral forms are used more often and are as effective and less painful than injections. Penicillin injections are recommended only if there is a concern that the patient will not comply with therapy. Robitussin DM may be used as an antitussive. For severe sore throats aspirin or Tylenol, or Tylenol with codeine may be given.

When a patient has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the patient very carefully because he or she is at high risk for

carotid artery hemorrhage. Explanation: The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. Pulmonary embolism is associated with immobility. Dehydration may lead to poor wound healing and breakdown. Pneumonia is a risk for any postoperative patient.

A client who has been diagnosed with an early glottis cancer would likely undergo which type of surgery?

laser microsurgery Explanation: In early glottis cancer, early stage lesions are treated and removed with a laser process. Vocal cord stripping would be the surgical treatment for early stage vocal cord lesions. Partial laryngectomy is done to treat early-stage laryngeal cancer when only one cord is involved. Total laryngectomy is done when the cancer extends beyond the vocal cords.