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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?
- A. Burning pain on swallowing
- B. Regurgitation of undigested food
- C. Symptoms mimicking a heart attack
- D. Chronic parotid abscesses
Correct Answer: B
Rationale: 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.
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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.
An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2 F 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?
- A. Palpate the patients parotid glands to detect swelling and tenderness.
- B. Assess the temporomandibular joint for evidence of a malocclusion.
- C. Test the integrity of cranial nerve XII by asking the patient to protrude the tongue.
- D. Inspect the patients gums for bleeding and hyperpigmentation.
Correct Answer: A
Rationale: 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 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?
- A. Ineffective Tissue Perfusion
- B. Impaired Skin Integrity
- C. Aspiration
- D. Imbalanced Nutrition: Less Than Body Requirements
Correct Answer: D
Rationale: 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 postoperative from a neck dissection. What would be the most appropriate nursing action to enhance the patients appetite?
- A. Encourage the family to bring in the patients favored foods.
- B. Limit visitors at mealtimes so that the patient is not distracted.
- C. Avoid offering food unless the patient initiates.
- D. Provide thorough oral care immediately after the patient eats.
Correct Answer: A
Rationale: 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 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?
- A. Assessing function of cranial nerves V, VI, and IX
- B. Assessing for a history of GERD
- C. Assessing for signs or symptoms of atherosclerosis
- D. Assessing the patency of the ulnar artery
Correct Answer: D
Rationale: 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.