Brunner: Chapter 39 Point

The nurse is caring for a client with a history of bulimia. The client complains of retrosternal pain and dysphagia after forcibly causing herself to vomit after a large meal. The nurse suspects which condition?

Boerhaave syndrome

The nurse is conducting a health instruction program on oral cancer. The nurse determines that the participants understand the instructions when they state

"Many oral cancers produce no symptoms in the early stages."

Which clinical manifestation is not associated with hemorrhage?

Bradycardia

Semi-Fowler position is maintained for at least which timeframe following completion of an intermittent tube feeding?

1 hour

The nurse is conducting a community education session on the prevention of oral cancers. The nurse includes which cancer as being a type of premalignant squamous cell skin cancer?

Actinic cheilitis

A client has undergone a radical neck dissection. His skin graft site is pale. This indicates which condition?

Arterial thrombosis

The nurse teaches the client with gastroesophageal reflux disease (GERD) which measure to manage the disease?

Avoid eating or drinking 2 hours before bedtime.

Which tube is a nasoenteric feeding tube?

Dobbhoff

Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?

Chancre

Which is an accurate statement regarding cancer of the esophagus?

Chronic irritation of the esophagus is a known risk factor.

Which is the primary symptom of achalasia?

Difficulty swallowing

The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?

Diuretics

The nurse is creating a discharge teaching plan for a client after surgery for oral cancer. Which should be included in the teaching plan? Select all that apply.

Follow-up dental appointment , Follow-up medical appointment , Use of humidification , Oral hygiene

The nurse is caring for a client during the postoperative period following radical neck dissection. Which finding should be reported to the physician?

High epigastric pain and/or discomfort

The nurse is planning care for a client with painful oral lesions. Which food should be included in the client's diet?

Jell-O

The nurse is caring for a client receiving chemotherapy. For which mouth conditions associated with HIV infection should the nurse assess? Select all that apply.

Kaposi sarcoma , Candidiasis , Stomatitis

For a client with salivary calculi, which procedure uses shock waves to disintegrate the stone?

Lithotripsy

The nurse working in the recovery room is caring for a client who had a radical neck dissection. The nurse notices that the client makes a coarse, high-pitched sound upon inspiration. Which intervention by the nurse is appropriate?

Notify the physician

The nurse is preparing to assess the donor site of a client who underwent a myocutaneous flap after a radical neck dissection. The nurse prepares to assess the most commonly used muscle for this surgery. Which muscle should the nurse assess?

Pectoralis major

The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?

Sialadenitis

Which term describes an inflammation of the salivary glands?

Sialadenitis

Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?

Sialolithiasis

A client receives tube feedings after an oral surgery. The nurse manages tube feedings to minimize the risk of aspiration. Which measure should the nurse include in the care plan to reduce the risk of aspiration?

Use semi-Fowler position during, and 60 minutes after, an intermittent feeding

The nurse confirms placement of a client's nasogastric (NG) tube using a combination of visual and pH assessment of the aspirate. The nurse determines that the NG tube remains properly placed when the pH of the aspirate is

acidic

The most significant complication related to continuous tube feedings is

the increased potential for aspiration.

The nurse collaborates with the physician and dietician to determine the best type of tube feeding for a client at risk for diarrhea due to hypertonic feeding solutions. Which type of feedings should the nurse suggest?

continuous feedings

The nurse is caring for client scheduled to undergo radical neck dissection. During preoperative teaching, the nurse states that an associated complication is

shoulder drop.

The most common symptom of esophageal disease is

dysphagia

The nurse provides health teaching to inform the client with oral cancer that

many oral cancers produce no symptoms in the early stages.

A client with gastroesophageal reflux disease (GERD) comes to the physician's office reporting a burning sensation in the esophagus. The nurse documents that the client is experiencing

pyrosis

The nurse cares for a client who receives feedings through a nasogastric (NG) tube and assesses the client for signs and symptoms of pulmonary complications. The nurse determines the client may be experiencing pulmonary complications when which sign is noted?

respiratory rate of 30

The client is on a continuous tube feeding. The nurse determines the tube placement should be checked every

shift