Medsurg Ch 18

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

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

Laryngeal cancer

The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?

Provide the client with audiovisual materials about the surgery.

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

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

A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is

amoxicillin-clavulanic acid.

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states

"Do not smoke and avoid being around others who are smoking."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

"I was chewing ice chips all day long."

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

Ineffective airway clearance related to excess mucus production

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 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."

A client comes into the emergency department with epistaxis. What intervention should the nurse perform when caring for a client with epistaxis?

Apply direct continuous pressure.

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.

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

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

A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?

Administer one intramuscular injection of penicillin.

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 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 nurse is providing discharge teaching for a client who had a laryngectomy. Which instruction should the nurse include in her teaching?

"Cover the stoma whenever you shower or bathe."

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?

"Gargle with a warm salt solution."

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."

The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.

100

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

2 to 12 days

A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?

20 mL or less

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

A permanent tracheal stoma would be necessary.

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

Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)?

Amoxicillin

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

Amoxicillin-clavulanic acid

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?

Apply an ice pack.

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 the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Bleeding

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

Check the clear fluid for glucose.

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

Edema of the upper airway

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

Edema of the upper airway

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

Emotional support

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 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

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?

Hypercapnia

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

Ineffective airway clearance

The nurse is caring for a client who underwent a laryngectomy. Which intervention will the nurse initially complete in an effort to meet the client's nutritional needs?

Initiate enteral feedings.

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

Nuchal rigidity

Which type of sleep apnea is characterized by lack of airflow due to pharyngeal occlusion?

Obstructive

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?

Partial laryngectomy

A nurse is providing instructions for the client with chronic rhinosinusitis. The nurse accurately tells the client:

Sleep with the head of bed elevated.

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

Swimming

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

Total laryngectomy

Another term for clergyman's sore throat is

chronic granular pharyngitis.

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

impaired verbal communication

Stiffness of the neck or inability to bend the neck is referred to as

nuchal rigidity.

The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid

swimming.

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