Chapter 22 test3
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
Postoperatively, the client may not be permitted to eat or drink for at least 7 days. Alternative sources of nutrition and hydration include IV fluids, enteral feedings through a nasogastric or gastrostomy tube, and parenteral nutrition. Once the client is permitted to resume oral feedings, thick liquids are offered; sweet foods are avoided because they cause increased salivation and decrease the client's appetite. The client's taste sensations are altered for a while after surgery because inhaled air passes directly into the trachea, bypassing the nose and the olfactory end organs. In time, however, the client usually accommodates to this change and olfactory sensation adapts; thus, seasoning is based on personal preferences.
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Hypercapnia
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 surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that: A permanent tracheal stoma would be necessary.
A total laryngectomy will result in a permanent stoma and total loss of voice. A partial laryngectomy involves the removal of one vocal cord. The voice is spared with the supraglottic laryngectomy. Removal of a portion of the vocal cord occurs with a hemilaryngectomy.
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."
If a total laryngectomy is scheduled, the client must understand that the natural voice will be lost but special training can provide a means for communicating. The client needs to know that until training is started, communication will be possible using the call light, through writing, or using a special communication board. The use of an electronic device is a long-term postoperative goal. The speech therapist will evaluate the client before surgery and establish a method of immediate postoperative communication.
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy? impaired verbal communication
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.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to: 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.
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
The client should seek medical assistance if swallowing is impaired to prevent aspiration. Following Maslow's hierarchy of needs, airway clearance is the highest priority.
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
Treatment of acute rhinosinusitis depends on the cause; a 5- to 7-day course of antibiotics is prescribed for bacterial cases. Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid ( Augmentin) is the antibiotic of choice. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
Which is the priority nursing diagnosis for a client undergoing a laryngectomy? Ineffective airway clearance
The priority nursing diagnosis is Ineffective airway clearance, utilizing the ABCs. Imbalanced nutrition: Less than body requirement, impaired verbal communication, and anxiety and depression are all potential nursing diagnoses, but the question is asking for the priority nursing diagnosis for this patient. The priority is to identify any issues related to impaired airway.
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. Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks.
Ice or cold compresses are applied four to six times a day, for several days, until the swelling is decreased. Packing is inserted to control bleeding. It would not be used to reshape the nose.
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."
A sudden and complete loss of voice and cough are symptoms of laryngitis. The nurse instructs the client to avoid irritants, such as smoking. Voice rest is indicated. Whispering places stress on the larynx. Inhaling cool steam or aerosol aids in the treatment. Dry air may make the symptoms worse. A "tickle" in the throat that many clients report is actually worsened with cold liquids.
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
After an initial hoarseness lasting longer than a month, clients with laryngeal cancer will feel a sensation of swelling or a lump in the throat or in the neck. Weight loss often occurs later in the progression of laryngeal cancer due to reduced calorie intake as a result of impaired swallowing and pain. Clients with laryngeal cancer may report burning in the throat when swallowing hot or citrus liquids. Clients with obstructive sleep apnea may experience a morning headache.
Which is the antibiotic of choice used to treat acute bacterial rhinosinusitis (ABRS)? Amoxicillin
Antibiotics should be administered as soon as the diagnosis of ABRS is established. Amoxicillin-clavulanic acid is the antibiotic of choice. For clients who are allergic to penicillin, doxycycline or respiratory quinolones, such as levofloxacin or moxifloxacin, can be used. Other antibiotics previously prescribed to treat ABRS, including cephalosporins such as cephalexin and cefuroxime, are no longer recommended because they are not effective in treating antibiotic-resistant organisms that are now more commonly implicated in ABRS.
Which of the following is the most effective treatment for obstructive sleep apnea (OSA)? Continuous positive airway pressure (CPAP)
CPAP is the most effective treatment for OSA because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently. BiPAP ventilation offers independent control of inspiratory and expiratory pressure while providing pressure support ventilation. Mechanical ventilation is not the most effective treatment for OSA. Administration of low-flow nasal oxygen at night can help relieve hypoxemia in some patients but has little effect on the frequency or severity of apnea.
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
Clients receiving tube feedings are positioned with the head of the bed at 30 degrees or higher during feedings and for 30 to 45 minutes after tube feedings. Clients receiving oral feedings are positioned with the head of the bed in an upright position for 30 to 45 minutes after feedings. For clients with a nasogastric or gastrostomy tube, the placement of the tube and residual gastric volume must be checked before each feeding.
Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require? Emotional support
Clients with a malignancy of the larynx require emotional support before and after surgery and help in understanding and choosing an alternative method of speech. It does not require a referral for counseling or vocational training. It also does not require family counseling.
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction t o the client and family? "Family members should continue to talk to the client."
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.
Wound drains, inserted during the laryngectomy, stay in place until what criteria are met? Drainage is <30 mL/day for 2 consecutive days.
Drains are removed when secretions are minimal, which usually is less than 30 mL for 48 straight hours.
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
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 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"
Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath.
The nurse is caring for a client following a tonsillectomy and adenoidectomy. Two hours after the procedure, the client begins to vomit large amounts of dark blood at frequent intervals and is tachycardic and febrile. After notifying the surgeon, the nurse obtains a light, mirror, gauze, and curved hemostats.
If the client vomits large amounts of dark blood at frequent intervals, if the pulse rate and temperature rise, or if the client becomes restless, the nurse notifies the surgeon immediately. The nurse should have the following items ready for examination of the surgical site for bleeding: a light, a mirror, gauze, curved hemostats, and a waste basin. It is not necessary for the nurse to stay at the client's bedside. Needle aspiration is a procedure considered for clients experiencing a peritonsillar abscess. Although oral suctioning may be needed at some point of care, it is not a priority at this time.
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include hoarseness
Signs of acute laryngitis include hoarseness or aphonia and severe cough. Other signs of acute laryngitis include a dry cough, and a sore throat that feels worse in the morning. If allergies are present, the uvula will be visibly edematous.
The nurse is providing discharge instructions for a client following laryngeal surgery. The nurse instructs the client to avoid swimming
Swimming is not recommended because a client with a laryngectomy can drown without submerging his or her face. Special precautions are needed in the shower to prevent water from entering the stoma. Wearing a loose-fitting plastic bib over the tracheostomy or simply holding a hand over the opening is effective. 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.
A nurse is caring for a client experiencing laryngeal obstruction. What clinical finding should lead the nurse to anticipate mechanical ventilation for the client? Retractions in the neck during inspiration
The nurse anticipates mechanical ventilation if the client is having neck retractions during inspiration. Rhonchi in the bronchial region is heard lower in the airways and crackles are heard in the base of the lungs. Diminished breath sounds that occur throughout are indicative of airway obstruction, not laryngeal swelling.
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
The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake.
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately? Bleeding
The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.
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
With severe respiratory distress in a status post adenoidectomy client, the nurse would suspect an airway issue related to edema of the upper airway. The scenario does not indicate infection, postoperative bleeding, or a plugged tracheostomy tube.
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 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.
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is amoxicillin-clavulanic acid.
Amoxicillin-clavulanic acid (Augmentin) is the antibiotic of choice to treat ABRS. For patients who are allergic to penicillin, doxycycline (Vibramycin) or respiratory quinolones such as levofloxacin (Levaquin) or moxifloxacin (Avelox) can be used. Other antibiotics prescribed previously to treat ABRS, including cephalosporins such as cephalexin (Keflex), cefuroxime (Ceftin), cefaclor (Ceclor), and cefixime (Suprax), trimethoprim-sulfamethoxazole (Bactrim, Septra), and macrolides such as clarithromycin (Biaxin) and azithromycin (Zithromax), are no longer recommended because they are not effective in treating antibiotic-resistant organism
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of 2 to 12 days
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 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
Hoarseness of more than 2 weeks' duration occurs in the patient with cancer in the glottic area, because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Later symptoms include dysphasia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unintentional weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis.
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 laryngetctomy
In a partial laryngectomy, a portion of the larynx is removed, along with one vocal cord and the tumor; all other structures remain. The airway remains intact, and the patient is expected to have no difficulty swallowing. During a supraglottic laryngectomy, a tracheostomy is left in place until the glottic airway is established. Hemilaryngectomy is done by splitting the thyroid cartilage of the larynx in the midline of the neck, and the portion of the vocal cord is removed with the tumor. During a total laryngectomy, a complete removal of the larynx is performed, including the hyoid bone, epiglottis, cricoids cartilage, and two or three rings of the trachea.
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 is one of the most preventable types of cancer; it can be prevented by abstaining from excessive drinking and smoking. Inhaling noxious fumes, such as in polluted air, is a risk factor for laryngeal cancer. Roughly 80% of laryngeal cancer cases occur in men. Squamous cell carcinoma accounts for most cases of 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 Nuchal rigidity
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 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 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.
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.
If a nurse is concerned that a client may not perform follow-up treatment for streptococcal pharyngitis, the highest priority is to administer penicillin as a one-time injection dose. Oral penicillin is as effective and less painful, but the client needs to take the full course of treatment to prevent antibiotic-resistant germs from developing. The nurse should provide oral and written instructions for the client, but this is not as high a priority as administering the penicillin. Having a homeless friend monitor the client's care does not ensure that the client will follow therapy.
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 adenoids or pharyngeal tonsils consist of lymphatic tissue near the center of the posterior wall of the nasopharynx. Infection of the adenoids frequently accompanies acute tonsillitis. Frequently occurring bacterial pathogens include group A, beta-hemolytic streptococcus, the most common organism.
The nurse is mentoring a new graduate nurse. Today, the two of you are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. What would the nurse respond? Select all that apply. Aspiration Infection Injury to the laryngeal nerve
The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall.
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 instructs the client to blow the nose before administering the nasal medication. The client should keep the head upright, not tilted back. The client should wait at least 1 minute before administering the second spray and clean the container after each use.
