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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.
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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.
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 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.
A patients neck dissection surgery resulted in damage to the patients superior laryngeal nerve. What area of assessment should the nurse consequently prioritize?
- A. The patients swallowing ability
- B. The patients ability to speak
- C. The patients management of secretions
- D. The patients airway patency
Correct Answer: A
Rationale: 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 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.