Chapter 18 Management of pts with upper respiratory tract disorders

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 3 to 6 months. 20 to 30 days. 2 to 12 days. 1 to 3 months.

2 to 12 days.

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? Provide the client with oral penicillin that will last for 5 days. Ask an accompanying homeless friend to monitor the client's follow-up. Provide emphatic oral instructions for the client. Administer one intramuscular injection of penicillin.

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? Burning of the throat when hot liquids are ingested Affected voice sounds Enlarged cervical nodes Dysphagia

Affected voice sounds

You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? Airway patency Psychologic status Pain level Level of consciousness

Airway patency

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

Amoxicillin

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 antihistamine such as Benadryl An ointment such as bacitracin An antiviral agent such as acyclovir An antibiotic such as amoxicillin

An antiviral agent such as acyclovir

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. Reassure the client that the nose is not fractured. Apply an ice pack to the nose. Administer prescribed oral ibuprofen (Motrin).

Check the clear fluid for glucose.

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? Plugged tracheostomy tube Post operative bleeding Infection Edema of the upper airway

Edema of the upper airway

A client stops breathing during sleep as a result of repetitive upper airway obstruction. To help decrease the frequency of the apneic episodes, the nurse intervenes by informing the client to: Take a hypnotic medication at hours of sleep. Eliminate alcohol ingestion. Sleep on the back. Use nasal oxygen at night.

Eliminate alcohol ingestion.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? Caution against frequent coughing. Encourage deep breathing every 2 hours. Provide meticulous mouth care every 4 hours. Monitor for signs of dysphagia.

Encourage deep breathing every 2 hours.

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction? Apply pressure to the convex portion of the nose Provide a splint postoperatively Ensure mouth breathing Apply a warm pack postoperatively

Ensure mouth breathing

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 Watery eyes Arthralgia Headache

Epistaxis

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? Gram-negative Klebsiella Pseudomonas aeruginosa Group A, beta-hemolytic streptococcus Staphylococcus aureus

Group A, beta-hemolytic streptococcus

Select the nursing diagnosis that would warrant immediate health care provider notification. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever Acute pain related to upper airway irritation secondary to an infection Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

The nurse makes the observations shown in the accompanying notes about a client who will be discharged following a laryngectomy. The nurse makes a referral to the home health nurse for client reteaching based on which observation? Use of non-sterile tissues to wipe secretions from the airway. Initial washing of hands after cleaning inner cannula. Client use of tweezers to remove encrustations. Wearing a loose-fitting cloth over the stoma.

Initial washing of hands after cleaning inner cannula.

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. Offer plenty of thin liquids. Liberally season foods. Encourage sweet foods.

Initiate enteral feedings.

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids? Hardened secretions Noisy breathing Erosion of the trachea Incrusted mucous membranes

Noisy breathing

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply. Apply ice or cold compresses for 20 minutes every hour for the first 24 hours. Keep the nasal packing in place for 72 hours to help reshape the form of the nose. Restrict from sports activities for 6 weeks. Check for any unusual changes in breathing during the first 48 hours. Elevate the head of the bed for sleeping during the first week. Observe for any clear drainage from either nostril.

Restrict from sports activities for 6 weeks. Check for any unusual changes in breathing during the first 48 hours. Elevate the head of the bed for sleeping during the first week. Observe for any clear drainage from either nostril.

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 Properly dispose of used tissues Place an ice collar on the throat to relieve soreness Stay in bed when experiencing a fever

Seek medical help if he experiences inability to swallow

Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis? MRI CT scan Sinus aspirates Sinus x-rays

Sinus aspirates

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided? Hand-held showers Coughing Wearing a scarf over the stoma Swimming

Swimming

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply. Refer the client to a physician for antibiotic therapy. Teach the client about handwashing. Administer oral ibuprofen. Provide warm salt-water gargles. Recommend guaifenesin.

Teach the client about handwashing. Administer oral ibuprofen. Provide warm salt-water gargles. Recommend guaifenesin.

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice? Laser surgery Radiation therapy Partial laryngectomy Total laryngectomy

Total laryngectomy

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Hypercapnia Pulmonary hypotension Systemic hypotension Increased smooth muscle contractility

You selected: HypercapniaCorrectExplanation:Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

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? discomfort when drinking cold liquids weight loss a feeling of swelling at the back of the throat headaches in the morning

a feeling of swelling at the back of the throat

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 pulmonary embolism. carotid artery hemorrhage. pneumonia. dehydration.

carotid artery hemorrhage.

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: 8 seconds with 4 episodes/hour. 4 seconds with 2 episodes/hour. 6 seconds with 3 episodes/hour. 10 seconds with 5 episodes/hour.

d. 10 seconds with 5 episodes/hour.Explanation:OSA is characterized by frequent and loud snoring, with breathing cessation for 10 seconds or longer, for at least five episodes per hour, followed by abrupt awakening with a loud snort as the blood oxygen level drops. Symptoms typically progress with weight gain, aging, and during the transition to menopause for women.

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. laryngeal cancer occurs primarily in women. adenocarcinoma accounts for most cases of laryngeal cancer. inhaling polluted air isn't a risk factor for laryngeal cancer.

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

A late complication of radiation therapy is pain. dysphasia. xerostomia. laryngeal necrosis.

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 orbital cellulitis. severe epistaxis. subperiosteal abscess. sinus infection.

sinus infection.

Late symptoms of laryngeal cancer include which of the following. Select all that apply. Dysphagia Dyspnea Persistent hoarseness Sore throat Burning in throat

Dysphagia Dyspnea Persistent hoarseness

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client? "Decrease oral intake if increased swallowing occurs." "You may have a sore throat for 1 week." "Gargle with a warm salt solution." "You are allowed to have hot tea or coffee."

"Gargle with a warm salt solution."

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

Bleeding

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include? "After surgery you will have a sore throat, but you will be able to speak." "After surgery you will have to use an electric larynx to communicate." "You can use writing or a communication board to communicate." "A speech therapist will evaluate you and recommend a system of communication after surgery."

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

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? No fluid is normally present 20 mL or less 20-40 mL More than 40 mL

20 or less

Which assessment finding puts a client at increased risk for epistaxis? Use of a humidifier at night History of nasal surgery Hypotension Cocaine use

Cocaine use

The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply. A temperature >100.4°F Red pharyngeal membranes Swollen lymphoid follicles A dry, nonproductive cough White-purple exudates on the back of the throat

A temperature >100.4°F Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat

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? Provide the client with oral penicillin that will last for 5 days. Ask an accompanying homeless friend to monitor the client's follow-up. Administer one intramuscular injection of penicillin. Provide emphatic oral instructions for the client.

Administer one intramuscular injection of penicillin.

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis? Place the client in a semi-Fowler's position. Apply direct continuous pressure. Apply a moustache dressing. Provide a nasal splint.

Apply direct continuous pressure.

An adolescent client sustains a fractured nose during a high school basketball game. Which action will the school nurse take first to help this client? Explain how the nose will need to be reset. Call for transportation to the nearest emergency room. Apply ice with the client in a seated position. Pack the nose with rolled gauze pads.

Apply ice with the client in a seated position.

An adolescent client sustains a fractured nose during a high school basketball game. Which action will the school nurse take first to help this client? Pack the nose with rolled gauze pads. Apply ice with the client in a seated position. Explain how the nose will need to be reset. Call for transportation to the nearest emergency room.

Apply ice with the client in a seated position.

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 Tilt the head back when activating the spray of the medication. Blow the nose before applying medication into the nares. Wait 10 seconds before administering the second spray. Clean the medication container once each day.

Blow the nose before applying medication into the nares.

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 Tilt the head back when activating the spray of the medication. Wait 10 seconds before administering the second spray. Clean the medication container once each day. Blow the nose before applying medication into the nares.

Blow the nose before applying medication into the nares.

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 Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD) Gastroesophageal reflux disease (GERD) Respiratory failure (RF)

Gastroesophageal reflux disease (GERD)

Which clinical manifestation of hemorrhage is related to carotid artery rupture? Shallow respirations Dry skin Increased blood pressure Increased pulse rate

Increased pulse rate

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 Acute pain related to upper airway irritation Deficient fluid volume related to increased fluid needs Ineffective airway clearance related to excess mucus production Deficient knowledge related to prevention of upper respiratory infections

Ineffective airway clearance related to excess mucus production

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect? Chronic tonsillitis Chronic pharyngitis Laryngeal polyps Laryngeal cancer

Laryngeal cancer

Blow the nose before applying medication into the nares.

Laryngeal cancer

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for Mild headache Nuchal rigidity Nausea Hypertension

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? Supraglottic laryngectomy Partial laryngectomy Total laryngectomy Hemilaryngectomy

Partial laryngectomy

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? Refer the client to a social worker or psychologist. Give the client his or her cell phone number. Reassure the client and family that outcomes are nearly always positive. Provide the client with audiovisual materials about the surgery.

Provide the client with audiovisual materials about the surgery

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 Exerts pressure against the worker's abdomen Places both arms around the worker's waist Makes a fist with one hand with the thumb outside the fist Stands behind the worker, who has hands across the neck

Stands behind the worker, who has hands across the neck

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? Look for a halo sign after the drainage dries. Have the client blow his nose. Test the nasal drainage for glucose. Contact the physician.

Test the nasal drainage for glucose.

Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare: Solid foods, so chewing can be reestablished to stimulate salivation. Thick liquids that are easy to swallow. Clear, warm liquids to slowly stimulate peristalsis. Soft, pureed foods, similar in consistency to baby food.

Thick liquids that are easy to swallow.

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 CBC with differential Magnetic resonance imaging (MRI) Nasal culture

Transillumination of the sinus

Most cases of acute pharyngitis are caused by which of the following? Systemic infection Viral infection Fungal infection Bacterial infection

Viral infection

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 states that there is discomfort and requests removal In 1 week when the patient no longer has serous drainage When the patient has less than 30 mL for 2 consecutive days When the drainage tube comes out

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

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 foul odor to your breath" difficulty swallowing foods" a persistent cough or sore throat" trouble with your breathing"

a persistent cough or sore throat"

A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include a sore throat that feels worse in the evening. hoarseness. a nonedematous uvula. a moist cough.

hoarseness. Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.

Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? impaired verbal communication deficient knowledge risk for chronic low self-esteem risk for infection

impaired verbal communication

client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: blow his nose and then put lateral pressure on his nose. sit upright, leaning slightly forward. lie supine with his neck extended. hold his nose while bending forward at the waist.

sit upright, leaning slightly forward. Sitting upright and leaning slightly forward avoids increasing vascular pressure in the nose and helps the client avoid aspirating blood. Lying supine won't prevent aspiration of the blood. Nose blowing can dislodge any clotting that has occurred. Bending at the waist increases vascular pressure in the nose and promotes bleeding rather than halting it.