CH 20 upper respiratory disorders

A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:

"I should become involved in a weight loss program."

A client is recovering from a tonsillectomy in the postanesthesia care unit. After an overnight stay in the hospital due to increased secretions and vomiting, the nurse delivers client education and accompanying paperwork. Which comment indicates that the client requires additional education?

"If I'm vomiting, I'll drink lemon-lime soda to keep myself hydrated."

The ET will maintain your airway while you're under anesthesia.

"The ET tube will maintain your airway while you're under anesthesia."

A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, "Does this kind of cancer tend to spread to other parts of the body?" What is the nurse's best response?

"This cancer usually does not spread to distant sites in the body."

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

''Do you smoke cigarettes, cigars, or a pipe?"

The nurse is caring for a client with allergic rhinitis. The c;ient asks the nurse about measures to help decrease allergic symptoms. Which is the best response by the nurse?

''You should try to reduce exposure to irritants and allergens."

A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which clients are at greatest risk for developing chronic pharyngitis?

A client who is a habitual user of alcohol and tobacco

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A permanent tracheal stoma would be necessary.

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

A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to:

Apply ice and tell the patient to keep his head elevated

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?

Applying nasal packing

The nurse is creating a plan of care for a client diagnosed with acute laryngitis. What intervention should be included in the client's plan of care?

Encourage the client to limit speech whenever possible.

A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem?

Encouraging the patient to avoid alcohol and hypnotic medications

The ED nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from her nose. What should the ED nurse suspect?

Fracture of the cribriform plate

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

Group A beta-hemolytic streptococcus

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

Group A, beta-hemolytic streptococci

The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?

Ineffective airway clearance related to airway alterations

The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client states that he has hereditary angioedema. The nurse should identify what implication of this health condition?

It can cause life-threatening airway obstruction.

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

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse's best action?

Rapidly assess the client and notify the surgeon about the client's bleeding.

A has entered the postanesthesia care unit following sinus surgery. What will the nurse monitor closely during the postoperative period?

Seek medical help if he experiences inability to swallow

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

Seek medical help if he experiences inability to swallow

A client who has an altered level of consciousness is receiving tube feedings. Clients receiving tube feeding should be placed in which position?

Semi-Fowler's or higher

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

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?

Symptom management is the main focus of medical and nursing care.

The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?

The client's airway patency

The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?

Tracheoesophageal puncture

It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?

Use of warm saline gargles or throat irrigations can relieve symptoms.

The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished?

Vigilant handwashing by staff and residents

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?

When the patient has less than 30 mL for 2 consecutive days

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

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 is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

ensure mouth breathing

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

fever

The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery?

hemmorrhage

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

hoarseness of more than 2 week's duration

The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?

hoarsness

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?

impaired verbal communication

A client is being seen by the physician because of an unrelenting headache, facial tenderness, low-grade fever, and dark yellow nasal discharge. The client reports seeming to develop sinus infections "all the time." Which factor may predispose the client to sinusitis?

interference with sinus drainage

The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?

keep a complete suction setup at the bedside.

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?

swimming

A client states that her family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to what factor?

the virus is shed for 2 days prior to the emergence of symptoms

The nurse is providing client teaching to a young mother who has brought her 3-month-old infant to the clinic for a well-baby checkup. What action should the nurse recommend to the woman to prevent the transmission of organisms to her infant during the cold season?

wash hands frequently