chapter 46 exam 1
An elderly patient is diagnosed with parotitis. The nurse is aware that this bacterial infection is most likely caused by: Pseudomonas. Pneumococcus. Staphylococcus aureus. Streptococcus viridans.
Staphylococcus aureus. Explanation: The elderly and debilitated experience decreased salivary flow from general dehydration or medications. The bacterial infection is usually caused by Staphylococcus aureus. The infecting organism travels from the mouth through the salivary gland.
x To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Take antacids with meals." "Limit fluid intake with meals."
"Avoid coffee and alcoholic beverages." Explanation: 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.
x A nurse caring for a patient who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. An expected normal amount of drainage is: Between 40 and 80 mL. Approximately 80 to 120 mL. Between 120 and 160 mL. Greater than 160 mL.
Approximately 80 to 120 mL. Explanation: 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.
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. Drink three, 8 oz. glasses of regular milk daily to coat the esophagus. Avoid beer, especially in the evening. Eat 1 hour before bedtime so there will be food in the stomach overnight to absorb excess acid. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows.
Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows. Explanation: Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.
The most common symptom of esophageal disease is which of the following? Nausea Vomiting Dysphagia Odynophagia
Dysphagia Explanation: Dysphagia may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain on swallowing. Nausea is the most common symptom of GI problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain on 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? Hiatal hernia Gastroesophageal reflux disease Gastritis Esophageal tumor
Esophageal tumor Explanation: 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." The nurse assesses the following as placing the client at risk: Exhibiting hemoglobin A1C 8.2 Drinking fluoridated water Eating fruits and cheese in diet Using a soft-bristled toothbrush
Exhibiting hemoglobin A1C 8.2 Explanation: 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.
x Postoperatively, a patient with a radical neck dissection should be placed in which position? Supine Fowler's Prone Side-lying
Fowler's Explanation: The patient should be placed in the Fowler's position to facilitate expansion of 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.
A client has a new order for metoclorpramide (Reglan). The nurse identifies that this medication can be safely administered for which conditon? Gastroesophageal reflux disease Peptic ulcer with melena Diverticulitis with perforation Gastritis
Gastroesophageal reflux disease Explanation: Metoclorpramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
Tyrone Freeman is a 49-year-old male being treated for GERD at the gastroenterology office where you work. During his visit, he states that his reflux is much improved, but now, he is having diarrhea. In addition to his prescribed treatment for GERD, he has been taking an antacid. Which of the following components of an antacid might be causing his diarrhea? Magnesium Aluminum Calcium None of the above
Magnesium Explanation: The magnesium component may tend to cause diarrhea in some clients. Magnesium can cause diarrhea in some clients.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying? Metoclopramide (Reglan) Famotidine (Pepcid) Nizatidine (Axid) Esomeprazole (Nexium)
Metoclopramide (Reglan) Explanation: 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), nizatidine (Axid), or ranitidine (Zantac). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.
A group of students is reviewing the medications that may be used to treat esophageal reflux. The students demonstrate understanding of the information when they identify which of the following as an example of a proton-pump inhibitor? Ranitidine (Zantac) Sucralfate (Carafate) Omeprazole (Prilosec) Cisapride (Propulsid)
Omeprazole (Prilosec) Explanation: Proton-pump inhibitors include omeprazole (Prilosec) and lansoprazole (Prevacid). Ranitidine (Zantac) is a histamine-2 antagonist; sucralfate (Carafate) is a cytoprotective agent; cisapride (Propulsid) is a gastrointestinal motility agent.
A client with a history of peptic ulcer disease is admitted for hematemesis associated with gastric bleeding. Which is the most appropriate action of the nurse? Administer oxygen. Increase intravenous flow rate. Prepare for nasogastric irrigations. Lower the head of the bed.
Prepare for nasogastric irrigations. Explanation: Hemorrhage with peptic ulcer disease is initially handled through cold saline lavage via nasogastric tube. Increasing the IV rate is not a nursing measure. Administering oxygen is not indicated unless the client is experiencing respiratory difficulties. While having hematemesis, the head of the bed would remain elevated to avoid risk for aspiration.
A client with esophageal cancer has difficulty in swallowing. Which of the following would be appropriate to help the client achieve improved nutrition? Give high-protein, semiliquid foods. Provide oral liquids through a straw. Give liquid supplements for meals. Encourage small, frequent meals.
Give high-protein, semiliquid foods. Explanation: A major goal for a client with esophageal cancer is adequate or improved nutrition and eventually stable weight. Because he has difficulty in swallowing, the nurse should ensure that the client receives soft foods or high-calorie, high-protein, semiliquid foods to get improved nutrition. Providing oral liquids alone will not provide improved nutrition. Using a straw leads to bloating and should be avoided. Providing liquid supplements are used in between meals, not as meals. Encouraging small, frequent meals will give improved nutrition to a client who does not have any difficulty in swallowing.
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 client cannot speak. Teach the client exercises for the neck and shoulder area to perform 1 day after surgery. Provide oxygen without humidity through the tracheostomy tube. Encourage the client to position himself on his side.
Make a notation on the call light system that the client cannot speak. Explanation: 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.
The nurse working in the recovery room is caring for a patient who had a radical neck dissection. The nurse notices that the patient has a coarse, high-pitched sound on inspiration. Which of the following is the appropriate intervention by the nurse? Documenting the presence of stridor Administering a breathing treatment Notifying the physician Lowering the head of the bed
Notifying the physician Explanation: The presence of stridor, a coarse, high-pitched sound on inspiration, in the immediate postoperative period following radical neck dissection indicates obstruction of the airway and requires that the nurse report it immediately to the physician.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client? Abdominal distention, elevated temperature, weakness before eating Constipation, rectal bleeding following bowel movements Persistent loose stools, chills, hiccups after eating Weakness, diaphoresis, diarrhea 90 minutes after eating
Weakness, diaphoresis, diarrhea 90 minutes after eating Explanation: 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.
The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which of the following as being a type of premalignant squamous cell skin cancer? Herpes simplex 1 Actinic cheilitis Chancre Krythoplakia
Actinic cheilitis Explanation: Actinic cheilitis is a type of premalignant squamous cell skin cancer that presents as scaling, crusty fissures or a white overgrowth of horny layers of the epidermis. Herpes simplex 1 is an opportunistic infection frequently seen in immunosuppressed patients. Chancres are reddened circumscribed lesions that ulcerate and become crusted and are the primary lesions of syphilis. Krythoplakia is a red patch on the oral mucous membrane that is frequently seen in the elderly.
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): Extension of the esophagus through an opening in the diaphragm. Involution of the esophagus, which causes a severe stricture. Protrusion of the upper stomach into the lower portion of the thorax. Twisting of the duodenum through an opening in the diaphragm.
Protrusion of the upper stomach into the lower portion of the thorax. Explanation: 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.
A patient with gastroesophageal reflux disease (GERD) comes to the physician's office with complaints of a burning sensation in the esophagus. The nurse documents that the patient is experiencing which of the following? Pyrosis Dyspepsia Dysphagia Odynophagia
Pyrosis Explanation: Pyrosis refers to a burning sensation in the esophagus and indicates GERD. Indigestion is termed dyspepsia. Difficulty swallowing is termed dysphagia. Pain on swallowing is termed odynophagia.
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client doesn't exhibit rectal tenesmus. The client is free from esophagitis and achalasia. The client reports diminished duodenal inflammation. The client has normal gastric structures.
The client is free from esophagitis and achalasia. Explanation: Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.