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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?
- A. Keep the head of the bed lowered.
- B. Drink a cup of hot tea before bedtime.
- C. Avoid carbonated drinks.
- D. Eat a low-protein diet.
Correct Answer: C
Rationale: 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.
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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?
- A. Encourage the patient to perform deep breathing and coughing exercises hourly.
- B. Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula.
- C. Activate the emergency response system.
- D. Report this finding promptly to the physician and remain with the patient.
Correct Answer: D
Rationale: 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 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?
- A. Indicates acceptance of altered appearance and demonstrates positive self-image
- B. Freely expresses needs and concerns related to postoperative pain management
- C. Compensates effectively for alteration in ability to communicate related to dysarthria
- D. Demonstrates effective stress management techniques to promote muscle relaxation
Correct Answer: A
Rationale: 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.
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?
- A. Dull pain radiating to the ears and teeth
- B. Presence of a painless sore with raised edges
- C. Areas of tenderness that make chewing difficult
- D. Diffuse inflammation of the buccal mucosa
Correct Answer: B
Rationale: 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 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 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?
- A. Document the findings as being consistent with a viable graft.
- B. Promptly report these indications of venous congestion.
- C. Closely monitor the patient and reassess in 30 minutes.
- D. Reposition the patient to promote peripheral circulation.
Correct Answer: B
Rationale: 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.