NUR 2211 Medical Surgical Nursing Chapter 9: Nursing Management: Patients With Upper Respiratory Tract Disorders (including end of chapter questions)

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 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 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.

The nurse is educating a patient diagnosed with acute bacterial rhinosinusitis about interventions that may assist with symptom control. What should the nurse include in this information? (Select all that apply.)

Ensure an adequate fluid intake. Increase the humidity in the home. Apply local heat to promote drainage.

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

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

It requires the insertion of a prosthesis into the trachea.

A client seeks medical attention for a hoarseness that has lasted for more than 2 weeks. Which additional finding indicates to the nurse that the client may need to be evaluated for cancer of the larynx?

Sore throat

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?

Use enteral feedings after the procedure

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 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 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.

An emergency department (ED) nurse is assessing a 20-year-old gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. What should the ED nurse suspect?

Fracture of the cribriform plate

What client would be most in need of an endotracheal tube?

Comatose clients

The medical nurse is creating the care plan of a client with a tracheostomy requiring mechanical ventilation. Which nursing action is most appropriate?

Monitor cuff pressure every 8 hours.

While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required:

When adventitious breath sounds are auscultated

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?

"You should rest, increase your fluids, and take Ibuprofen."

The nurse is caring for a client with allergic rhinitis. The client 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."

The health care provider has ordered continuous positive airway pressure (CPAP) with the delivery of oxygenation. The patient asks the nurse what the benefit of CPAP is. What would be the nurse's best response?

CPAP prevents the collapse of the patient's airway

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use

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

The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?

Epistaxis

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

Most cases of acute pharyngitis are caused by which of the following?

Viral infection

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

Volume cycled

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

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

laryngeal cancer is one of the most preventable types of cancer.

A late complication of radiation therapy is

laryngeal necrosis.

The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing

sinus infection.

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is,

"Do you have a persistent cough or sore throat"

A patient who has just had a total laryngectomy for cancer is being discharged. Which statement indicates the patient needs further teaching on care of the tracheostomy?

"I can take a shower when I get home."

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."

Which statement indicates further teaching is required for the patient diagnosed with obstructive sleep apnea (OSA)?

"I will use the CPAP machine only when I really need to sleep well."

A college student has sought care at the campus medical clinical after a 5-day history of malaise that he believes is due to a bad cold. Which of the student's following statements should cause the nurse to suspect an alternative diagnosis?

"I've been burning up with a fever at night and then getting terrible chills too."

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."

A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response?

"When an endotracheal tube is left in too long it can damage the lining of the windpipe."

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

"You can use writing or a communication board to communicate."

An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for:

10 seconds with 5 episodes/hour.

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

2 to 12 days

The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

20 cm H2O

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

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy?

A client requires permanent ventilation.

What is obstructive sleep apnea?

A condition that can be treated, but not cured, by the use of a CPAP; failure to use the CPAP at night can cause nasopharyngeal structures to collapse, which will impair the airway.

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

A face mask

A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks with the assistance of a surgically implanted device. The nurse is correct to provide teaching on which method?

A tracheoesophageal puncture

What is a complication of GAS pharyngitis?

Acute poststreptococcal glomerulonephritis (APSGN) is a complication that follows roughly 10 days after the onset of streptococcal infection and results in temporary kidney failure.

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.

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

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently?

Airway patency

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

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

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 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.

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

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 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 providing preoperative teaching for the patient who is to undergo a total laryngectomy. Which nursing intervention is most important?

Assessing the patient's ability to read and write

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP)

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.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

Encourage deep breathing every 2 hours.

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 nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

Epistaxis

A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes

Gastroesophageal reflux disease (GERD)

The nurse would assess the patient with acute pharyngitis for what signs and symptoms that indicate a complication of GAS pharyngitis?

Gross hematuria, edema, and hypertension

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

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?

Hoarseness for 2 weeks

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

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

The nurse is preparing the care plan for a patient who is scheduled for a laryngectomy. Which nursing diagnosis should receive the highest priority?

Ineffective airway clearance related to surgical alterations in the airway

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 comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

Laryngeal cancer

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 caring for a client receiving radiation therapy for laryngeal cancer. Which is a late complication of radiation therapy?

Laryngeal necrosis

The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?

Monitor the pressure in the cuff at least every 8 hours

A patient with a diagnosis of acute rhinosinusitis has approached the nurse and asked for advice about "rinsing out my sinuses with saltwater," a treatment that was suggested by a friend. The nurse's response should be premised on which of the following statements?

Nasal saline lavage can help to improve the patency of the sinuses.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

Noisy breathing

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

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 23-year-old man has missed numerous work days over the past 2 years as a result of chronic viral pharyngitis. The nurse who is providing care for this patient should recognize that this patient may benefit from:

Tonsillectomy

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

Penicillin

A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by

Placing the client prone with the head turned to the side

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?

Prepare to administer subcutaneous epinephrine and corticosteroids.

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

A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to

Report relief of pain to level 3 using a pain intensity scale of 0 to 10.

A client is experiencing acute viral rhinosinusitis. The nurse is providing instructions about self-care activities and includes information about

Saline lavages to the nares

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

Sleep with the head of bed elevated.

A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply.

Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed

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

A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by

Telling the client to sit upright with the head tilted forward

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

Total laryngectomy

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

Test the nasal drainage for glucose.

The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes?

The cough reflex is depressed.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be:

The importance of complying with CPAP despite the inconvenience associated with its use

The nurse assesses a client who has a nasogastric tube for long-term nutritional needs for complications associated with the medical device. Complete the following sentence by choosing from the lists of options.

The nurse monitors the client for purulent nasal drainage, a finding indicative of rhinosinusitis, a noted complication of nasogastric tubes.

The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?

Transillumination of the sinus

What is removed in a total laryngectomy?

Vocal cords, so the patient will be unable to speak; the nurse should establish a means of communication prior to the procedure for the post-op period

A patient will be going home with a tracheal stoma. What information would be important to include in the discharge teaching for this patient?

Wear a medical identification bracelet.

When a client has undergone a laryngectomy and there is evidence of wound breakdown, the nurse monitors the client very carefully because of the high risk for

carotid artery hemorrhage.

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include

hoarseness.

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

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

permanent tracheal stoma would be necessary.

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

sit upright, leaning slightly forward.