Honan-Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders
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?" -"Have you strained your voice recently?" -"Do you eat a lot of red meat?" -"Do you eat spicy foods?"
Correct response: "Do you smoke cigarettes, cigars, or a pipe?" Explanation: Persistent hoarseness may signal throat cancer, which commonly is associated with tobacco use. To assess the client's risk for throat cancer, the nurse should ask about smoking habits. Although straining the voice may cause hoarseness, it wouldn't cause hoarseness lasting for 1 month. Consuming red meat or spicy foods isn't associated with persistent hoarseness.
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family? -"Clean the tracheostomy tube with alcohol and water." -"Family members should continue to talk to the client." -"Oral intake of fluids should be limited for 1 week only." -"Limit the amount of protein in the diet."
Correct response: "Family members should continue to talk to the client." Explanation: Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? -"The ET tube will maintain your airway while you're under anesthesia." -"The ET tube will be inserted through an opening in your trachea." -"The ET tube will remain in place for at least a day postsurgery." -"The ET tube will be connected to a negative-pressure ventilator."
Correct response: "The ET tube will maintain your airway while you're under anesthesia." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or who are comatose.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of -2 to 12 days. -20 to 30 days. -1 to 3 months. -3 to 6 months.
Correct response: 2 to 12 days. Explanation: HSV-1 is transmitted primarily by direct contact with infected secretions. The time periods of 20 to 30 days, 1 to 3 months, and 3 to 6 months exceed the incubation period.
A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? -Apply a moustache dressing. -Provide a nasal splint. -Apply direct continuous pressure. -Place the client in a semi-Fowler's position.
Correct response: Apply direct continuous pressure. Explanation: The severity and location of bleeding determine the treatment of a client with epistaxis. To manage this condition, the nurse should apply direct continuous pressure to the nares for 5 to 10 minutes with the client's head tilted slightly forward. Application of a moustache dressing or a drip pad to absorb drainage, application of a nasal splint, and placement of the client in a semi-Fowler's position are interventions related to the management of a client with a nasal obstruction
The nurse is providing discharge instructions to a client who has nasal packing in place following nasal surgery. Which discharge instructions would be most appropriate for the client? -Avoid sports activities for 6 weeks. -Decrease the amount of daily fluids. -Take aspirin for nasal discomfort. -Administer normal saline nasal drops as ordered.
Correct response: Avoid sports activities for 6 weeks. Explanation: The nurse instructs the client to avoid sports activities for 6 weeks. There is no indication for the client to refrain from taking oral fluids. Mouth rinses help to moisten the mucous membranes and to reduce the odor and taste of dried blood in the oropharynx and nasopharynx. The client should take analgesic agents, such as acetaminophen or NSAIDs (i.e., ibuprofen or naproxen), to decrease nasal discomfort, not aspirin. The client does not need to use nasal drops when nasal packing is in place.
A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for -Hypertension -Mild headache -Nuchal rigidity -Nausea
Correct response: Nuchal rigidity Explanation: Potential complications of acute bacterial rhinosinusitis are nuchal rigidity and severe headache. Hypertension may be a result of over-the-counter decongestant medications. Nausea may be a result of nasal corticosteroids.
A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client: -Sleep with the head of bed elevated. -Caffeinated beverages are allowed. -You may drink 1 glass of alcohol daily. -Do not perform saline irrigations to the nares.
Correct response: Sleep with the head of bed elevated. Explanation: General nursing interventions for chronic rhinosinusitis include teaching the client how to provide self-care. These measures include elevating the head of the bed to promote sinus drainage. Caffeinated beverages and alcohol may cause dehydration. Saline irrigations are used to eliminate drainage from the sinuses.
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 -Places both arms around the worker's waist -Makes a fist with one hand with the thumb outside the fist -Exerts pressure against the worker's abdomen
Correct response: Stands behind the worker, who has hands across the neck Explanation: The description of the fellow worker is a person who is choking. Following guidelines set by the American Heart Association, the nurse first stands behind the person who is choking.
The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely? -"I have environmental allergies." -"I smoke a pack of cigarettes a day." -"I used my voice in excess over the weekend." -"I was chewing ice chips all day long."
Correct response: "I was chewing ice chips all day long." Explanation: Chewing ice chips, a form of pica if in excess, is not likely to cause laryngitis. Allergies, smoking, and excessive use of the voice causing straining are frequent causes.
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? -Apply a warm pack postoperatively -Ensure mouth breathing -Apply pressure to the convex portion of the nose -Provide a splint postoperatively
Correct response: Ensure mouth breathing Explanation: For a client who has undergone surgery for a nasal obstruction, it is important for the nurse to emphasize that nasal packing will be in place postoperatively, necessitating breathing through the mouth. The nurse applies an ice pack to reduce pain and swelling and not a warm pack. The nurse recommends the use of a splint and the application of pressure to the convex portion of the nose in case of a nasal fracture.
The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition? -Epistaxis -Xerostomia -Rhinorrhea -Dysphagia
Correct response: Epistaxis Explanation: Epistaxis is due to rupture of tiny, distended vessels in the mucous membrane of any area of the nose. Xerostomia refers to dryness of the mouth. Rhinorrhea refers to drainage of a large amount of fluid from the nose. Dysphagia refers to difficulties swallowing.
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? -Hoarseness -Dyspnea -Dysphagia -Alopecia
Correct response: Hoarseness Explanation: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Alopecia is not associated with a diagnosis of laryngeal cancer.
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention? -Epistaxis, twice last week -Aphonia following a football game -Hoarseness for 2 weeks -Laryngitis following a cold
Correct response: Hoarseness for 2 weeks Explanation: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
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 -Providing a high-calorie diet for residents -Encouraging residents' fluid intake -Providing topical decongestants to residents
Correct response: Vigilant handwashing by staff and residents Explanation: Thorough handwashing is the mainstay of URI prevention. Nutritious diet, high fluid intake, and the use of decongestants may be necessary treatments for residents who have URIs, but none of these measures appreciably protects against the development of URIs.
Which assessment finding puts a client at increased risk for epistaxis? -Use of a humidifier at night -Hypotension -Cocaine use -History of nasal surgery
Correct response: Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis.
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? -Incrusted mucous membranes -Hardened secretions -Erosion of the trachea -Noisy breathing
Correct response: Noisy breathing Explanation: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following a tracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
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? -Total laryngectomy -Cordectomy -Vocal cord stripping -Partial laryngectomy
Correct response: Partial laryngectomy Explanation: A partial laryngectomy (laryngofissure-thyrotomy) is often used for patients in the early stages of cancer in the glottis area when only one vocal cord is involved.
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage? -Rapid, deep respirations -Decreased pulse rate -Increased blood pressure -Warm, moist skin
Correct response: Rapid, deep respirations Explanation: The nurse monitors the vital signs for increased pulse rate, decreased blood pressure, rapid deep respirations, restlessness, and delayed capillary refill. Cold, clammy skin may indicate active bleeding.
A 64-year-old patient and his wife have presented to their primary care provider. The patient's wife has prompted her husband to seek care because she is worried about his apneic episodes and loud snoring. The husband had earlier undergone a diagnostic workup for obstructive sleep apnea (OSA) and been diagnosed with the disease but is not motivated to treat his health problem. How can the nurse at the clinic best characterize the risks of OSA? -"Sleep apnea actually increases your risk of having a stroke or heart attack." -"People with sleep apnea are much more susceptible to infections in their sinuses and throat." -"Sleep apnea has actually been identified as a risk factor for throat cancer." -"Without treatment, your sleep apnea could progress to chronic obstructive lung disease."
Correct response: "Sleep apnea actually increases your risk of having a stroke or heart attack." Explanation: OSA is associated with myocardial infarction and stroke, but it is not known to contribute to chronic obstructive lung disease, infections, or cancer.
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? -Hand-held showers -Wearing a scarf over the stoma -Swimming -Coughing
Correct response: Swimming Explanation: The nurse provides the client and family with the following postoperative instructions: water should not enter the stoma because it will flow from the trachea to the lungs. Therefore, the nurse instructs the client to avoid swimming and to use a handheld shower device when bathing. The nurse also suggests that the client wear a scarf over the stoma to make the opening less obvious. The nurse encourages the client to cough every 2 hours to promote effective gas exchange.
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? -impaired verbal communication -deficient knowledge -risk for infection -risk for chronic low self-esteem
Correct response: impaired verbal communication Explanation: Loss of the ability to speak normally is a devastating consequence of laryngeal surgery and is certain with a total laryngectomy. Issues with self-esteem and deficient knowledge are possible, but less certain. Infection is a risk, but not a certainty.