NSG 330 Ch 45- Management w/ Oral & Esophageal Disorders
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction?
"Avoid coffee and alcoholic beverages." To prevent reflux of stomach acid into the esophagus, the nurse should advise the client to avoid foods and beverages that increase stomach acid, such as coffee and alcohol. The nurse also should teach the client to avoid lying down after meals, which can aggravate reflux, and to take antacids after eating. The client need not limit fluid intake with meals as long as the fluids aren't gastric irritants.
A client who has occasional gastric symptoms is receiving teaching on how to prevent gastroesophageal reflux disease (GERD). Which statement indicates the client understands the teaching?
"I will eliminate bothersome foods from my diet." Explanation: Irritating foods such as spices, caffeine, and alcohol should be avoided because doing so will assist in decreasing gastric acidity. Eating smaller meals is recommended to avoid lower pressure in the lower esophageal sphincter. Gastric reflux of acid is more likely to occur with positioning flat and lying down after a meal, so this should be avoided.
A patient returns to the unit after a neck dissection. The surgeon placed a Jackson Pratt drain in the wound. When assessing the wound drainage over the first 24 postoperative hours the nurse would notify the physician immediately for what?
60 mL of milky or cloudy drainage Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours. Milky drainage is indicative of a chyle fistula, which requires prompt treatment.
A client is recovering from a neck dissection. What volume of serosanguineous secretions would the nurse expect to drain over the first 24 hours?
80 to 120 mL Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.
A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What patient most likely faces the highest immediate risk of oral cancer?
A 65-year-old man with alcoholism who smokes Oral cancers are often associated with the use of alcohol and tobacco, which when used together have a synergistic carcinogenic effect. Most cases of oral cancers occur in people over the age of 60 and a disproportionate number of cases occur in men. Diabetes, dentures, dental caries, and GERD are not risk factors for oral cancer.
When assessing a client during a routine checkup, the nurse reviews the history and notes that the client had aphthous stomatitis at the time of the last visit. How is aphthous stomatitis best described by the nurse?
A canker sore of the oral soft tissues Aphthous stomatitis refers to a canker sore of the oral soft tissues, including the lips, tongue, and inside of the cheeks. Aphthous stomatitis isn't an acute stomach infection, acid indigestion, or early sign of peptic ulcer disease.
A patient tells the nurse that it feels like food is "sticking" in the lower portion of the esophagus. What motility disorder does the nurse suspect these symptoms indicate?
Achalasia Explanation: Achalasia is absent or ineffective peristalsis of the distal esophagus accompanied by failure of the esophageal sphincter to relax in response to swallowing. Narrowing of the esophagus just above the stomach results in a gradually increasing dilation of the esophagus in the upper chest. The main symptom is difficulty in swallowing both liquids and solids. The patient has a sensation of food sticking in the lower portion of the esophagus.
While stripping wax from surfboards, a client accidentally ingested a refrigerated strong base cleaning solution, thinking it was water. What interventions would the nurse anticipate including in this client's care plan? Select all that apply.
Administer medication for report of pain. Insert an intravenous (IV) catheter for administration of IV fluids. Maintain nothing by mouth status. Assess respiratory status every 4 hours and prn. Explanation: The client who has a chemical burn of the oral mucosa and esophagus will experience pain and may experience respiratory distress. Based on the anticipated orders by the health care provider, the nurse will administer medication for pain and assess respiratory status. The client will be NPO, and IV fluids will be administered. Vomiting is avoided to prevent additional trauma from the caustic agent.
A patient who had a hemiglossectomy earlier in the day is assessed postoperatively, revealing a patent airway, stable vital signs, and no bleeding or drainage from the operative site. The nurse notes the patient is alert. What is the patients priority need at this time?
An effective means of communicating with the nurse Verbal communication may be impaired by radical surgery for oral cancer. It is therefore vital to assess the patients ability to communicate in writing before surgery. Emotional support and dietary teaching are critical aspects of the plan of care; however, the patients ability to communicate would be essential for both. Referral to a speech therapist will be required as part of the patients rehabilitation; however, it is not a priority at this particular time. Communication with the nurse is crucial for the delivery of safe and effective care.
A community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis?
An older adult whose medication regimen includes an anticholinergic Elderly, acutely ill, or debilitated people with decreased salivary flow from general dehydration or medications are at high risk for parotitis. Anticholinergic medications inhibit saliva production. Antibiotics, diabetes, and wounds are not risk factors for parotitis.
The nurse is examining the mouth of a client who is HIV positive. On the inner side of the lip, the nurse sees a shallow ulcer with a yellow center and red border. The client says the area has been painful for about 5 days or so. Which condition is most consistent with these findings?
Aphthous stomatitis Aphthous stomatitis is characterized by a shallow ulcer with a white or yellow center and red border, often on the inner lip and cheek or on the tongue. It begins with a burning or tingling sensation and slight swelling, and is painful, usually lasting 7 to 10 days. Aphthous ulcers are associated with HIV infection. Kaposi's sarcoma and hairy leukoplakia also are found in clients who are HIV positive. Kaposi's sarcoma is marked by red, purple, or blue lesions on the oral mucosa; hairy leukoplakia is characterized by white patches with rough hair-like projections typically on the lateral border of the tongue. A chancre is a reddened, circumscribed lesion that ulcerates and becomes crusted--it is a primary lesion of syphilis.
A nurse is completing an assessment on a client with a postoperative neck dissection. The nurse notices excessive bleeding from the dressing site and suspects possible carotid artery rupture. What action should the nurse take first?
Apply pressure to the bleeding site The first action for the nurse is to apply pressure to the bleeding site. The nurse will need to obtain assistance, elevate the head of the bed, and notify the surgeon, but client care is most important initially.
While caring for a patient who has had radical neck surgery, the nurse notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What does the nurse know is an expected amount of drainage in the wound unit?
Approximately 80 to 120 mL Wound drainage tubes are usually inserted during surgery to prevent the collection of fluid subcutaneously. The drainage tubes are connected to a portable suction device (e.g., Jackson-Pratt), and the container is emptied periodically. Between 80 and 120 mL of serosanguineous secretions may drain over the first 24 hours.
A nurse caring for a client who has had radical neck surgery notices an abnormal amount of serosanguineous secretions in the wound suction unit during the first postoperative day. What is an expected, normal amount of drainage?
Approximately 80 to 120 mL Explanation: Between 80 to 120 mL may drain over the first 24 hours. Drainage of greater than 120 mL may be indicative of a chyle fistula or hemorrhage.
A nurse is assessing a patient who has just been admitted to the postsurgical unit following surgical resection for the treatment of oropharyngeal cancer. What assessment should the nurse prioritize?
Assess for a patent airway Postoperatively, the nurse assesses for a patent airway. The patients ability to manage secretions has a direct bearing on airway patency. However, airway patency is the overarching goal. This immediate physiologic need is prioritized over communication, though this is an important consideration. Infection is not normally a threat in the immediate postoperative period.
The nurse is preparing to receive a client on the medical-surgical floor who has undergone neck dissection surgery. Which actions will the nurse take to assess for potential hemorrhage from the surgical site? Select all that apply.
Assess for epigastric pain Observe dressing for bleeding Instruct to avoid the Valsalva maneuver Monitor vital signs every 4 hours when stable After neck dissection surgery, hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery from the tumor or infection. The nurse should assess for epigastric pain as this is a sign of an impending rupture. Dressings should be monitored for excessive bleeding. The Valsalva maneuver is to be avoided as this will stress the graft and carotid artery. Vital signs should be monitored every 4 hours once the client is stabilized. The head of the bed should be elevated at least 30 degrees to maintain a patent airway and prevent aspiration.
A client in the emergency department reports that a piece of meat became stuck in the throat while eating. The nurse notes the client is anxious with respirations at 30 breaths/min, frequent swallowing, and little saliva in the mouth. An esophagogastroscopy with removal of foreign body is scheduled for today. What would be the first activity performed by the nurse?
Assess lung sounds bilaterally. All these activities are things the nurse may do for a client with a foreign body in the esophagus. This client is at risk for esophageal perforation, and thus pneumothorax. By auscultating lung sounds the nurse will be able to assess if a pneumothorax is present. The client has little saliva in the oral cavity and does not need to be suctioned. A client may also report pain with a foreign body. However, ABCs (airway, breathing, circulation) take priority. The consent for the esophagogastroscopy may be obtained after the nurse has completed the client assessment.
A client is postoperative following a graft reconstruction of the neck. What intervention is the most important for the nurse to complete with the client?
Assess the graft for color and temperature. Assessing the graft for color and temperature addresses circulation and is most important for the nurse to complete. Reinforcing the neck dressing is important, but not the priority. Administering medication and cleansing the drain site are not most important interventions with the client after graft reconstruction of the neck.
A client with achalasia recently underwent pneumatic dilation. The nurse intervenes after the procedure by
Assessing lung sounds Esophageal perforation is a risk following dilation of the esophagus. One way to assess is auscultating lung sounds. Airway and breathing are priorities according to Maslow's hierarchy of needs. The client is kept NPO until the gag reflex has returned. A barium swallow may be performed after an esophageal dilation if a perforation is suspected. Pain medication is administered for the procedure, but the client should have little pain after the procedure. Pain could indicate perforation.
A radial graft is planned in the treatment of a patients oropharyngeal cancer. In order to ensure that the surgery will be successful, the care team must perform what assessment prior to surgery?
Assessing the patency of the ulnar artery If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The success of this surgery is not primarily dependent on CN function or the absence of GERD and atherosclerosis.
The nurse notes that a patient who has undergone skin, tissue, and muscle grafting following a modified radical neck dissection requires suctioning. What is the most important consideration for the nurse when suctioning this patient?
Avoid applying suction on or near the suture line The nurse should avoid positioning the suction catheter on or near the graft suture lines. Application of suction in these areas could damage the graft. Self-sectioning may be unsafe because the patient may damage the suture line. Following a modified radical neck dissection with graft, the patient is usually positioned with the head of the bed elevated to promote drainage and reduce edema. Assessing viability of the graft is important but is not part of the suctioning procedure and may delay initiating suctioning. Maintenance of a patent airway is a nursing priority. Similarly, the patients ability to swallow is an important assessment for the nurse to make; however, it is not directly linked to the patients need for suctioning.
Health teaching for a patient with GERD is directed toward decreasing lower esophageal sphincter pressure and irritation. The nurse instructs the patient to do which of the following? Select all that apply.
Avoid beer, especially in the evening. Elevate the head of the bed on 6- to 8-inch blocks. Elevate the upper body on pillows. Explanation: Milk should be avoided, as should eating before bed. Advise the patient not to eat or drink 2 hours before bedtime.
A nurse is providing health promotion education to a patient diagnosed with an esophageal reflux disorder. What practice should the nurse encourage the patient to implement?
Avoid carbonated drinks. For a patient diagnosed with esophageal reflux disorder, the nurse should instruct the patient to keep the head of the bed elevated. Carbonated drinks, caffeine, and tobacco should be avoided. Protein limitation is not necessary.
A nurse is caring for a patient who has just had a rigid fixation of a mandibular fracture. When planning the discharge teaching for this patient, what would the nurse be sure to include?
Avoiding chewing food for the specified number of weeks after surgery The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. Increased calcium intake will not have an appreciable effect on healing. Enteral and parenteral nutrition are rarely necessary.
The nurse is creating a plan of care for a client who is not able to tolerate brushing his teeth. The nurse includes which mouth irrigation in the plan of care?
Baking soda and water When a client is unable to tolerate teeth brushing, the following irrigating solutions are recommended: 1 tsp baking soda in 8 oz warm water, half-strength hydrogen peroxide, or normal saline solution.
Which clinical manifestation is not associated with hemorrhage?
Bradycardia Hemorrhage may occur from carotid artery rupture as a result of necrosis of the graft or damage to the artery itself from tumor or infection. Tachycardia, tachypnea, and hypotension may indicate hemorrhage and impending hypovolemic shock.
A client has been receiving radiation therapy to the lungs and now has erythema, edema, and pain of the mouth. What instruction will the nurse give to the client?
Brush and floss daily. Explanation: The description of erythema, edema, and pain of the mouth following radiation treatment describes stomatitis. Nursing considerations include prophylactic mouth care such as brushing and flossing daily. A soft-bristled toothbrush is recommended. The client is to avoid alcohol-based mouth rinses and hot or spicy foods that may be part of the client's usual diet.
A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation?
Brushing the patients teeth with a toothbrush and small amount of toothpaste Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.
A nurse inspects the Stensen duct of the parotid gland to determine inflammation and possible obstruction. What area in the oral cavity would the nurse examine?
Buccal mucosa next to the upper molars The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.
Which term describes a reddened, circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis?
Chancre A chancre is a reddened circumscribed lesion that ulcerates and becomes crusted and is a primary lesion of syphilis. Lichen planus is a white papule at the intersection of a network of interlacing lesions. Actinic cheilitis is an irritation of the lips associated with a scaling, crusting fissure. Leukoplakias are white patches usually found in the buccal mucosa.
Which is the primary symptom of achalasia?
Difficulty swallowing The primary symptom of achalasia is difficulty in swallowing both liquids and solids. The client may also report chest pain and heartburn that may or may not be associated with eating. Secondary pulmonary complications may result from aspiration of gastric contents.
The nurse is caring for an older adult who reports xerostomia. The nurse evaluates for use of which medication?
Diuretics Explanation: Diuretics, frequently taken by older adults, can cause xerostomia (dry mouth). This is uncomfortable, impairs communication, and increases the client's risk for oral infection. Antibiotics, antiemetics, and steroids are not medications typically taken orally by adults that cause dry mouth.
The nurse is obtaining a history on a patient who comes to the clinic. What symptom described by the patient is one of the first symptoms associated with esophageal disease?
Dysphagia Dysphagia (difficulty swallowing), the most common symptom of esophageal disease, may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute odynophagia (pain on swallowing).
A nurse is addressing the prevention of esophageal cancer in response to a question posed by a participant in a health promotion workshop. What action has the greatest potential to prevent esophageal cancer?
Early diagnosis and treatment of gastroesophageal reflux disease There are numerous risk factors for esophageal cancer but chronic esophageal irritation or GERD is among the most significant. This is a more significant risk factor than dietary habits. Screening endoscopies are not recommended solely on the basis of family history.
When caring for a client with the impaired swallowing related to neuromuscular impairment, what is the nurse's priority intervention?
Elevate the head of the bed 90 degrees during meals. The head of the bed must be elevated while the client is eating. The client should be placed in a recumbent position — not a supine position — when lying down to reduce the risk of aspiration. The nurse should encourage the client to wear properly fitted dentures to enhance his chewing ability. Thick liquids — not thin — decrease the risk of aspiration.
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about how to reduce reflux. What should the nurse include in the teaching? Select all that apply.
Encourage the client to eat frequent, small, well-balanced meals. Inform the client to remain upright for at least 2 hours after meals. Instruct the client to avoid alcohol or tobacco products. Instruct the client to eat slowly and chew the food thoroughly. Explanation: The nurse should encourage the client to eat frequent, small, well-balanced meals, inform the client to remain upright for at least 2 hours after meals, instruct the client to avoid alcohol or tobacco products, and instruct the client to eat slowly and chew the food thoroughly when teaching the client how to reduce reflux. The nurse should discourage the client from eating before bedtime.
A nurse is caring for a patient who is postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite?
Encourage the family to bring in the patients favored foods. Family involvement and home-cooked favorite foods may help the patient to eat. Having visitors at mealtimes may make eating more pleasant and increase the patients appetite. The nurse should not place the complete onus for initiating meals on the patient. Oral care after meals is necessary, but does not influence appetite
A nurse is caring for a patient who has had surgery for oral cancer. When addressing the patients longterm needs, the nurse should prioritize interventions and referrals with what goal?
Enhancement of verbal communication Verbal communication may be impaired by radical surgery for oral cancer. Addressing this impairment often requires a long-term commitment. Immune function, social support, and fluid balance are all necessary, but communication is a priority issue for patients recovering from this type of surgery.
A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status?
Ensure that none of the patients visitors has an infection Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.
An older adult client seeks medical attention for a report of general difficulty swallowing. Which assessment finding is most significant as related to this symptom?
Esophageal tumor Esophageal tumor is most significant and can result in advancing cancer. Esophageal cancer is a serious condition that presents with a symptom of difficulty swallowing as the tumor grows. Hiatal hernia, gastritis, and GERD can lead to serious associated complications but less likely to be as significant as esophageal tumor/cancer.
Cancer of the esophagus is most often diagnosed by which of the following?
Esophagogastroduodenoscopy (EGD) with biopsy and brushings Currently, diagnosis is confirmed most often by EGD with biopsy and brushings. The biopsy can be used to determine the presence of disease and cell differentiation. X-ray, barium swallow, and fluoroscopy are used in the diagnosis of hiatal hernia.
An elderly client states, "I don't understand why I have so many caries in my teeth." What assessment made by the nurse places the client at risk for dental caries?
Exhibiting hemoglobin A1C 8.2 Measures used to prevent and control dental caries include controlling diabetes. A hemoglobin A1C of 8.2 is not controlled. It is recommended for hemoglobin A1C to be less than 7 for people with diabetes. Other measures to prevent and control dental caries include drinking fluoridated water; eating foods that are less cariogenic, which include fruits, vegetables, nuts, cheese, or plain yogurt; and brushing teeth evenly with a soft-bristled toothbrush.
A client has a new order for metoclopramide. What potential side effects should the nurse educate the client about?
Extrapyramidal Explanation: Metoclopramide (Reglan) is a prokinetic agent that accelerates gastric emptying. Because metoclopramide can have extrapyramidal side effects that are increased in certain neuromuscular disorders, such as Parkinson's disease, it should be used only if no other option exists, and the client should be monitored closely. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
Postoperatively, a client with a radical neck dissection should be placed in which position?
Fowler The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position expands the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs.
A client has a new order for metoclopramide. The nurse identifies that this medication can be safely administered for which condition?
Gastroesophageal reflux disease Metoclopramide is a prokinetic agent that accelerates gastric emptying. It is contraindicated with hemorrhage or perforation. It is not used to treat gastritis.
A patient describes a burning sensation in the esophagus, pain when swallowing, and frequent indigestion. What does the nurse suspect that these clinical manifestations indicate?
Gastroesophageal reflux disease Symptoms may include pyrosis (burning sensation in the esophagus), dyspepsia (indigestion), regurgitation, dysphagia or odynophagia (pain on swallowing), hypersalivation, and esophagitis.
An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body?
Glucagon Glucagon is administered prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for patients with myastheniagravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm
During a psychotic episode, a client with schizophrenia swallows a small wooden spoon. Which medication would the nurse in the emergency department be most likely to administer to facilitate removal of the foreign body?
Glucagon Explanation: Glucagon is administered before removing a foreign body because it relaxes the smooth muscle of the esophagus, thereby facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Insulin and epinephrine would not assist with foreign body removal.
A client with human immunodeficiency virus (HIV) comes to the clinic and is experiencing white patches on the lateral border of the tongue. What type of lesions does the nurse document?
Hairy leukoplakia Hairy leukoplakia is a condition often seen in people who are HIV positive in which white patches with rough, hairlike projections form, typically on lateral border of the tongue. Aphthous stomatitis is typically a recurrent round or oval sore or ulcer on the inside of the lips and cheeks or underneath the tongue and is not associated with HIV. Erythroplakia describes a red area or red spots on the lining of the mouth and is not associated with HIV. Nicotine stomatitis is a white patch in the mouth caused by extreme heat from smoking.
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 Explanation: The nurse should report high epigastric pain and/or discomfort because this can be a sign of impending rupture. Crackles that clear after coughing, serous drainage on the dressing, and a temperature of 99.0°F are normal findings in the immediate postoperative period and do not need to be reported to the physician.
A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?
Imbalanced Nutrition: Less Than Body Requirements Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.
A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries?
Inadequate nutrition and decreased saliva production can cause cavities Many ill patients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the patient is not significant in the development of dental caries in the ill patient.
A client is being evaluated for esophageal cancer. What initial manifestation of esophageal cancer should the nurse assess?
Increasing difficulty in swallowing The client first becomes aware of intermittent and increasing difficulty in swallowing with esophageal cancer. As the tumor grows and the obstruction becomes nearly complete, even liquids cannot pass into the stomach. Other clinical manifestations may include the sensation of a mass in the throat, foul breath, and hiccups, but these are not the most common initial clinical manifestation with clients with esophageal cancer.
A medical nurse who is caring for a patient being discharged home after a radical neck dissection has collaborated with the home health nurse to develop a plan of care for this patient. What is a priority psychosocial outcome for a patient who has had a radical neck dissection?
Indicates acceptance of altered appearance and demonstrates positive self-image Since radical neck dissection involves removal of the sternocleidomastoid muscle, spinal accessory muscles, and cervical lymph nodes on one side of the neck, the patients appearance is visibly altered. The face generally appears asymmetric, with a visible neck depression; shoulder drop also occurs frequently. These changes have the potential to negatively affect self-concept and body image. Facilitating adaptation to these changes is a crucial component of nursing intervention. Patients who have had head and neck surgery generally report less pain as compared with other postoperative patients; however, the nurse must assess each individual patients level of pain and response to analgesics. Patients may experience transient hoarseness following a radical neck dissection; however, their ability to communicate is not permanently altered. Stress management is beneficial but would not be considered the priority in this clinical situation
A nurse is providing care for a patient whose neck dissection surgery involved the use of a graft. When assessing the graft, the nurse should prioritize data related to what nursing diagnosis?
Ineffective Tissue Perfusion Grafted skin is highly vulnerable to inadequate perfusion and subsequent ischemia and necrosis. This is a priority over chronic pain, which is unlikely to be a long-term challenge. Neglect and disuse are not risks related to the graft site.
A client has a radical neck dissection to treat cancer of the neck. The nurse develops the care plan and includes all the following diagnoses. The nurse identifies the highest priority diagnosis as
Ineffective airway clearance related to obstruction by mucus
A patient seeking care because of recurrent heartburn and regurgitation is subsequently diagnosed with a hiatal hernia. Which of the following should the nurse include in health education?
Instead of eating three meals a day, try eating smaller amounts more often. Management for a hiatal hernia includes frequent, small feedings that can pass easily through the esophagus. Avoiding beverages and particular foods or taking OTC antacids are not noted to be beneficial.
A client has a cheesy white plaque in the mouth. The plaque looks like milk curds and can be rubbed off. What is the nurse's best intervention?
Instruct the client to swish prescribed nystatin solution for 1 minute. A cheesy white plaque in the mouth that looks like milk curds and can be rubbed off is candidiasis. The most effective treatment is antifungal medication such as nystatin (Mycostatin). When used as a suspension, the client is to swish vigorously for at least 1 minute and then swallow. Other measures such as providing saline rinses or ingesting a soft or bland diet are comfort measures. The nurse does not remove the plaques; doing so will cause erythema and potential bleeding.
Results of a patient barium swallow suggest that the patient has GERD. The nurse is planning health education to address the patients knowledge of this new diagnosis. Which of the following should the nurse encourage?
Keeping the head of the bed slightly elevated The patient with GERD is encouraged to elevate the head of the bed on 6- to 8-inch (15- to 20-cm) blocks. Frequent meals are not specifically encouraged and the patient should avoid food and fluid within 2 hours of bedtime. All carbonated beverages should be avoided.
Which of the following is a proton pump inhibitor used in the treatment of gastroesophageal reflux disease (GERD)? Select all that apply.
Lansoprazole (Prevacid) Rabeprazole (AcipHex) Esomeprazole (Nexium)
A staff educator is reviewing the causes of gastroesophageal reflux disease (GERD) with new staff nurses. What area of the GI tract should the educator identify as the cause of reduced pressure associated with GERD?
Lower esophageal sphincter The lower esophageal sphincter, also called the gastroesophageal sphincter or cardiac sphincter, is located at the junction of the esophagus and the stomach. An incompetent lower esophageal sphincter allows reflux (backward flow) of gastric contents. The upper esophageal sphincter and the hypopharyngeal sphincter are synonymous and are not responsible for the manifestations of GERD. The pyloric sphincter exists between the stomach and the duodenum.
Which of the following are functions of saliva? Select all that apply.
Lubrication Protection against harmful bacteria Digestion Explanation: The three main functions of saliva are lubrication, protection against harmful bacteria, and digestion. Elimination and metabolism are not functions of saliva.
A client who reports increasing difficulty swallowing, weight loss, and fatigue is diagnosed with esophageal cancer. Because this client has difficulty swallowing, what should the nurse assign highest priority to?
Maintaining a patent airway Rapid growth of cancer cells in the esophagus may put pressure on the adjacent trachea, jeopardizing the airway. Therefore, maintaining a patent airway is the highest care priority for a client with esophageal cancer. Helping the client cope with body image changes, ensuring adequate nutrition, and preventing injury are appropriate for a client with this disease, but are less crucial than maintaining airway patency.
A client with cancer has a neck dissection and laryngectomy. An intervention that the nurse will do is:
Make a notation on the call light system that the client cannot speak. The client who has a laryngectomy cannot speak. Other personnel need to know this when answering the call light system. Exercises for the neck and shoulder are usually started after the drains have been removed and the neck incision is sufficiently healed. Humidified oxygen is provided through the tracheostomy to keep secretions thin. To prevent pneumonia, the client should be placed in a sitting position.
A patient has been diagnosed with a malignancy of the oral cavity and is undergoing oncologic treatment. The oncologic nurse is aware that the prognosis for recovery from head and neck cancers is often poor because of what characteristic of these malignancies?
Metastases are common and respond poorly to treatment. Deaths from malignancies of the head and neck are primarily attributable to local-regional metastasis to the cervical lymph nodes in the neck. This often occurs by way of the lymphatics before the primary lesion has been treated. This local-regional metastasis is not amenable to surgical resection and responds poorly to chemotherapy and radiation therapy. This high mortality rate is not related to surgical complications, late diagnosis, or the development of brain tumors.
A patient with GERD has undergone diagnostic testing and it has been determined that increasing the pace of gastric emptying may help alleviate symptoms. The nurse should anticipate that the patient may be prescribed what drug?
Metoclopramide (Reglan) Metoclopramide (Reglan) is useful in promoting gastric motility. Omeprazole and lansoprozole are proton pump inhibitors that reduce gastric acid secretion. Famotidine (Pepcid) is an H2 receptor antagonist, which has a similar effect.
Which of the following medications, used in the treatment of GERD, accelerate gastric emptying?
Metoclopramide (Reglan) Explanation: Prokinetic agents which accelerate gastric emptying, used in the treatment of GERD, include bethanechol (Urecholine), domperidone (Motilium), and metoclopramide (Reglan). If reflux persists, the patient may be given antacids or H2 receptor antagonists, such as famotidine (Pepcid) or nizatidine (Axid). Proton pump inhibitors (medications that decrease the release of gastric acid, such as esomeprazole (Nexium) may be used, also.
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 presence of stridor, a coarse, high-pitched sound upon inspiration, in the immediate postoperative period following radical neck dissection, indicates obstruction of the airway, and the nurse must report it immediately to the physician.
The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay?
Organic fruit juice Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.
An elderly patient comes into the emergency department complaining of an earache. The patient and has an oral temperature of 100.2F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
Palpate the patients parotid glands to detect swelling and tenderness Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.
A patient reports an inflamed salivary gland below the right ear. The nurse documents probable inflammation of which gland?
Parotid Explanation: The salivary glands consist of the parotid glands, one on each side of the face below the ear; the submandibular and sublingual glands, both in the floor of the mouth; and the buccal gland, beneath the lips.
A nurse is caring for a patient in the late stages of esophageal cancer. The nurse should plan to prevent or address what characteristics of this stage of the disease? Select all that apply.
Perforation into the mediastinum Erosion into the great vessels Obstruction of the esophagus In the later stages of esophageal cancer, obstruction of the esophagus is noted, with possible perforation into the mediastinum and erosion into the great vessels. Painful swallowing and the emergence of a lesion are early signs of esophageal cancer.
The client has returned to the floor following a radical neck dissection. Anesthesia has worn off. What is the nurse's priority action?
Place the client in the Fowler's position. Explanation: All the options are activities the nurse may do; however, the nurse has to prioritize according to Maslow's hierarchy of needs. Physiological needs are addressed first. Under physiological needs, ABCs (airway, breathing, circulation) take priority. Placing the client in the Fowler's position facilitates breathing and promotes comfort.
A patient has undergone surgery for oral cancer and has just been extubated in postanesthetic recovery. What nursing action best promotes comfort and facilitates spontaneous breathing for this patient?
Placing the patient in Fowlers position After the endotracheal tube or airway has been removed and the effects of the anesthesia have worn off, the patient may be placed in Fowlers position to facilitate breathing and promote comfort. Lateral positioning does not facilitate oxygenation or comfort. Medications do not facilitate spontaneous breathing.
A patient who underwent surgery for esophageal cancer is admitted to the critical care unit following postanesthetic recovery. Which of the following should be included in the patients immediate postoperative plan of care?
Positioning the patient to prevent gastric reflux After recovering from the effects of anesthesia, the patient is placed in a low Fowlers position, and later in a Fowlers position, to help prevent reflux of gastric secretions. The patient is observed carefully for regurgitation and dyspnea because a common postoperative complication is aspiration pneumonia. In this period of recovery, self-suctioning is also not likely realistic or safe. Chest physiotherapy is contraindicated because of the risk of aspiration. Nutrition is prioritized, but a regular diet is contraindicated in the immediate recovery from esophageal surgery.
The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
Presence of a painless sore with raised edges Malignant lesions of the oral cavity are most often painless lumps or sores with raised borders. Because they do not bother the patient, delay in seeking treatment occurs frequently, and negatively affects prognosis. Dull pain radiating to the ears and teeth is characteristic of malocclusion. Inflammation of the buccal mucosa causes discomfort and often occurs as a side effect of chemotherapy. Tenderness resulting in pain on chewing may be associated with gingivitis, abscess, irritation from dentures, and other causes. Pain related to oral cancer is a late symptom.
A patient who has had a radical neck dissection is being prepared for discharge. The discharge plan includes referral to an outpatient rehabilitation center for physical therapy. What would the goals of physical therapy for this patient include?
Promoting maximum shoulder function Shoulder drop occurs as a result of radical neck dissection. Shoulder function can be improved by rehabilitation exercises. Rehabilitation would not be initiated until the patients neck incision and graft, if present, were sufficiently healed. Nerve paralysis in the cervical plexus and other variables affecting swallowing would be managed by a speech therapist rather than a physical therapist.
A patient has undergone rigid fixation for the correction of a mandibular fracture suffered in a fight. What area of care should the nurse prioritize when planning this patients discharge education?
Promotion of adequate nutrition The patient who has had rigid fixation should be instructed not to chew food in the first 1 to 4 weeks after surgery. A liquid diet is recommended, and dietary counseling should be obtained to ensure optimal caloric and protein intake. The nature of this surgery threatens the patients nutritional status; this physiologic need would likely supersede the resumption of ADLs. Pain should be under control prior to discharge and communication is not precluded by this surgery.
A nurse is caring for a patient who has undergone neck resection with a radial forearm free flap. The nurses most recent assessment of the graft reveals that it has a bluish color and that mottling is visible. What is the nurses most appropriate action?
Promptly report these indications of venous congestion. A graft that is blue with mottling may indicate venous congestion. This finding constitutes a risk for tissue ischemia and necrosis; prompt referral is necessary.
A nurse practitioner, who is treating a patient with GERD, knows that this type of drug helps treat the symptoms of the disease. The drug classification is:
Proton pump inhibitors. Explanation: Proton pump inhibitors are the strongest inhibitors of acid secretions. The H2-receptor antagonists are the next most powerful.
A patient has been diagnosed with a hiatal hernia. The nurse explains the diagnosis to the patient and his family by telling them that a hernia is a (an):
Protrusion of the upper stomach into the lower portion of the thorax. It is important for the patient and his family to understand the altered association between the esophagus and the stomach. The diaphragm opening, through which the esophagus passes, becomes enlarged and part of the upper stomach moves up into the lower portion of the thorax. The abnormality is not an involuntary, protruding, or twisted segment.
A client with a disorder of the oral cavity cannot tolerate tooth brushing or flossing. Which strategy should the nurse use to assist the client?
Provide the client with an irrigating solution of baking soda and warm water. If a client cannot tolerate brushing or flossing, an irrigating solution of 1 tsp of baking soda to 8 oz of warm water, half strength hydrogen peroxide, or normal saline solution is recommended. Using tap water is not enough to promote oral hygiene. Drinking a small glass of alcohol will not provide oral hygiene. Wiping the outside of the mouth will not promote oral hygiene.
A patient has been diagnosed with an esophageal diverticulum after undergoing diagnostic imaging. When taking the health history, the nurse should expect the patient to describe what sign or symptom?
Regurgitation of undigested food An esophageal diverticulum is an outpouching of mucosa and submucosa that protrudes through the esophageal musculature. Food becomes trapped in the pouch and is frequently regurgitated when the patient assumes a recumbent position. The patient may experience difficulty swallowing; however, burning pain is not a typical finding. Symptoms mimicking a heart attack are characteristic of GERD. Chronic parotid abscesses are not associated with a diagnosis of esophageal diverticulum.
A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action?
Report this finding promptly to the physician and remain with the patient. In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.
A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this patient?
Respiratory status and airway clearance Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. The other assessments are part of the plan of care for a patient who has had a radical neck dissection, but are not the nurses chief priority.
A patient has been diagnosed with achalasia based on his history and diagnostic imaging results. The nurse should identify what risk diagnosis when planning the patients care?
Risk for Aspiration Related to Inhalation of Gastric Contents Achalasia can result in the aspiration of gastric contents. It is not normally an acute risk to the patients nutritional status and does not affect cardiac output or communication.
Which of the following refers to a bacterial or viral infection of the salivary glands?
Sialadenitis Sialadenitis refers to the bacterial or viral infection of the salivary glands. Parotitis (inflammation of the parotid gland) is the most common inflammatory condition of the salivary glands. Mumps (epidemic parotitis), a communicable disease caused by viral infection and most commonly affecting children, is an inflammation of a salivary gland, usually the parotid. Stomatitis involves inflammation and breakdown of the oral mucosa; it is often a side effect of chemotherapy or radiation therapy.
The nurse notes that a client has inflammation of the salivary glands. The nurse documents which finding?
Sialadenitis Explanation: Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
Which term describes an inflammation of the salivary glands?
Sialadenitis Explanation: Sialadenitis is inflammation of the salivary glands. Parotitis is inflammation of the parotid glands. Stomatitis is inflammation of the oral mucosa. Pyosis is pus.
Which term is used to describe stone formation in a salivary gland, usually the submandibular gland?
Sialolithiasis Salivary stones are formed mainly from calcium phosphate. Parotitis refers to inflammation of the parotid gland. Sialadenitis refers to inflammation of the salivary glands. Stomatitis refers to inflammation of the oral mucosa.
An older adult patient who has been living at home alone is diagnosed with parotitis. What causative bacteria does the nurse suspect is the cause of the parotitis?
Staphylococcus aureus People who are older, acutely ill, or debilitated with decreased salivary flow from general dehydration or medications are at high risk for parotitis. The infecting organisms travel from the mouth through the salivary duct. The organism is usually Staphylococcus aureus (except in mumps).
A client has been diagnosed with Zenker's diverticulum. What treatment does the nurse include in the client education?
Surgical removal of the diverticulum Explanation: Because Zenker's diverticulum is progressive, the only means of cure is surgical removal of the diverticulum. A low-residue diet will not stop the progression of the disease. Chemotherapy and radiation therapy will not target the specific site of the Zenker's diverticulum.
A client with an esophageal stricture is about to undergo esophageal dilatation. As the bougies are passed down the esophagus, the nurse should instruct the client to do which action to minimize the vomiting urge?
Take long, slow breaths During passage of the bougies used to dilate the esophagus, the client should take long, slow breaths to minimize the vomiting urge. Having the client hold the breath, bear down as if having a bowel movement, or pant like a dog is neither required nor helpful.
The client has a chancre on the lips. What instruction should the nurse provide?
Take measures to prevent spreading the lesion to other people. A chancre is a primary lesion of syphilis and very contagious. It is important to instruct the client about ways to prevent spreading the lesion to others. Other nursing considerations include cold soaks to the lip, good mouth care (brushing and flossing), and administration of antibiotics as prescribed.
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge?
The client is free from esophagitis and achalasia. Dysphagia may be the reason why a client with esophagitis or achalasia seeks treatment. Therefore, when the client is free of esophagitis or achalasia, he is ready for discharge. Dysphagia isn't associated with rectal tenesmus, duodenal inflammation, or abnormal gastric structures.
A nurse enters the room of a client who has returned to the unit after having a radical neck dissection. Which assessment finding requires immediate intervention?
The client lying in a lateral position, with the head of bed flat A client who has had neck surgery is at risk for neck swelling. To prevent respiratory complications, the head of the bed should be at least at a 30-degree angle. This position gives the lungs room to expand and decreases swelling by promoting venous and lymphatic drainage. This position also minimizes the risk of aspiration. Serosanguineous drainage on the dressing, a Foley bag containing amber urine, and levofloxacin infusing aren't causes for concern.
A patient with gastroesophageal reflux disease (GERD) has a diagnosis of Barretts esophagus with minor cell changes. Which of the following principles should be integrated into the patients subsequent care?
The patient will require an upper endoscopy every 6 months to detect malignant changes. In the patient with Barretts esophagus, the cells lining the lower esophagus have undergone change and are no longer squamous cells. The altered cells are considered precancerous and are a precursor to esophageal cancer. In order to facilitate early detection of malignant cells, an upper endoscopy is recommended every 6 months. H2 receptor antagonists are commonly prescribed for patients with GERD; however, monitoring of liver enzymes is not routine. Stools that contain evidence of frank bleeding or that are tarry are not expected and should be reported immediately. When antacids are prescribed for patients with GERD, they should be taken as ordered whether or not the patient is symptomatic.
A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?
The patients swallowing ability If the superior laryngeal nerve is damaged, the patient may have difficulty swallowing liquids and food because of the partial lack of sensation of the glottis. Damage to this particular nerve does not inhibit speech and only affects management of secretions and airway patency indirectly.
A nurse in an oral surgery practice is working with a patient scheduled for removal of an abscessed tooth. When providing discharge education, the nurse should recommend which of the following actions?
Use warm saline to rinse the mouth as needed. The patient should be assessed for bleeding after the tooth is extracted. The mouth can be rinsed with warm saline to keep the area clean. A firm toothbrush or toothpick could injure the tissues around the extracted area. Alcohol would injure tissues that are healing
Cardiac complications, which may occur following resection of an esophageal tumor, are associated with irritation of which nerve at the time of surgery?
Vagus Explanation: Cardiac complications include atrial fibrillation, which occurs due to irritation of the vagus nerve at the time of surgery. The hypoglossal nerve controls muscles of the tongue. The vestibulocochlear nerve functions in hearing and balance. The trigeminal nerve functions in chewing of food.
Which of the following assessment findings would be most important for indicating dumping syndrome in a postgastrectomy client?
Weakness, diaphoresis, diarrhea 90 minutes after eating Dumping syndrome produces weakness, dizziness, sweating, palpitations, abdominal cramping, and diarrhea from the rapid emptying of the chyme after eating. Elevated temperature and chills can be a significant finding for infection and should be reported. Constipation with rectal bleeding is not indicative of dumping syndrome.
Which of the following is the most common type of diverticulum?
Zenker's diverticulum Explanation: The most common type of diverticulum, which is found three times more frequently in men than women, is Zenker's diverticulum (also known as pharyngoesophageal pulsion diverticulum or a pharyngeal pouch).
The most common symptom of esophageal disease is
dysphagia. This symptom may vary from an uncomfortable feeling that a bolus of food is caught in the upper esophagus to acute pain upon swallowing. Nausea is the most common symptom of gastrointestinal problems in general. Vomiting is a nonspecific symptom that may have a variety of causes. Odynophagia refers specifically to acute pain upon swallowing.
The nurse provides health teaching to inform the client with oral cancer that
many oral cancers produce no symptoms in the early stages. The most frequent symptom of oral cancer is a painless sore that does not heal. The client may complain of tenderness, and difficulty with chewing, swallowing, or speaking occur as the cancer progresses. Biopsy is used to diagnose oral cancer. A typical lesion in oral cancer is a painless, hardened ulcer with raised edges.
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question?
metoclopramide Explanation: The instructions are appropriate for the client experiencing gastroesophageal reflux disease. The client is prescribed carbidopa/levodopa (Sinemet), which is used for Parkinson's disease. Metoclopramide can have extrapyramidal effects, and these effects can be increased in clients with Parkinson's disease.
The healthcare provider of a client with oral cancer has ordered the placement of a GI tube to provide nutrition and to deliver medications. What would be the preferred route?
nasogastric intubation Explanation: The nasal route is the preferred route for passing a tube when the client's nose is intact and free from injury.
A client has received a diagnosis of oral cancer. During client education, the client expresses dismay at not having recognized any early signs or symptoms of the disease. The nurse tells the client that in early stages of this disease:
there are usually no symptoms.
A client who had oral cancer has had extensive surgery to excise the malignancy. Although surgery was deemed successful, it was quite disfiguring and incapacitating. What is essential to this client and family?
time to mourn, accept, and adjust to the loss The first time family members or clients see the effects of surgery, the experience usually is traumatic. The nurse needs to promote effective coping and therapeutic grieving at this time. Responses may range from crying or extreme sadness and avoiding contact with others to refusing to talk about the surgery or changes in appearance. Allowing the client time to mourn, accept, and adjust to losses is essential.
