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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?
- A. Risk for Disuse Syndrome
- B. Unilateral Neglect
- C. Risk for Trauma
- D. Ineffective Tissue Perfusion
Correct Answer: D
Rationale: 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.
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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?
- A. Risk for Aspiration Related to Inhalation of Gastric Contents
- B. Risk for Imbalanced Nutrition: Less than Body Requirements Related to Impaired Absorption
- C. Risk for Decreased Cardiac Output Related to Vasovagal Response
- D. Risk for Impaired Verbal Communication Related to Oral Trauma
Correct Answer: A
Rationale: 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.
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?
- A. Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash
- B. Applying a water-soluble gel to the teeth and gums
- C. Wiping the teeth and gums clean with a gauze pad
- D. Brushing the patients teeth with a toothbrush and small amount of toothpaste
Correct Answer: D
Rationale: 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 community health nurse serves a diverse population. What individual would likely face the highest risk for parotitis?
- A. A patient who is receiving intravenous antibiotic therapy in the home setting
- B. A patient who has a chronic venous ulcer
- C. An older adult whose medication regimen includes an anticholinergic
- D. A patient with poorly controlled diabetes who receives weekly wound care
Correct Answer: C
Rationale: 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.
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?
- A. Perforation into the mediastinum
- B. Development of an esophageal lesion
- C. Erosion into the great vessels
- D. Painful swallowing
- E. Obstruction of the esophagus
Correct Answer: A,C,E
Rationale: 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.
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?
- A. Radiation therapy often results in secondary brain tumors.
- B. Surgical complications are exceedingly common.
- C. Diagnosis rarely occurs until the cancer is endstage.
- D. Metastases are common and respond poorly to treatment.
Correct Answer: D
Rationale: 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.