Nokea
The client with vocal cord polypusis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration.
- A. Tilt the head back as far as possible when swallowing.
- B. Tuck the chin down when swallowing.
- C. Breathe slowly and deeply while swallowing.
- D. Keep the head very still and straight while swallowing.
Correct Answer: B
Rationale: Tucking the chin down during swallowing helps prevent aspiration by closing off the airway. Tilting the head back would increase the chance of aspiration. Breathing slowly or keeping the head still does not specifically reduce aspiration risk.
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A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretion? (Select all that apply.)
- A. A 24-year-old with a traumatic brain injury.
- B. A 36-year-old who fractured his left femur.
- C. A 30-year-old at risk for aspiration following radiation therapy.
- D. A 60-year-old who is quadriplegic and has a sacral ulcer.
- E. An 80-year-old who is aphasic after a cerebral vascular accident.
Correct Answer: A,C,D,E
Rationale: Clients with traumatic brain injury, aspiration risk post-radiation, quadriplegia, or aphasia are at risk for asphyxiation due to impaired ability to manage secretions. A fractured femur does not increase this risk.
A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture.
- A. You will need to cut the wires if you start vomiting.
- B. Eat soft or liquid meals each day while recovering.
- C. Irrigate your mouth every 2 hours to prevent infection.
- D. Sleep in a semi-Fowler's position after the surgery.
- E. Gargle with mouthwash that contains Benadryl once a day.
Correct Answer: A,B,C,D
Rationale: The client should be taught to cut wires in case of vomiting to prevent aspiration, eat soft or liquid meals, irrigate the mouth to prevent infection, and sleep in a semi-Fowler's position to reduce aspiration risk. Benadryl mouthwash is not indicated for this condition.
A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?
- A. Add peppermint oil to the humidifier to relax the airway.
- B. Make sure you clean the humidifier to prevent infection.
- C. Keep the humidifier filled with water at all times.
- D. Use the humidifier when you sleep, even during daytime naps.
Correct Answer: B
Rationale: Cleaning the humidifier is critical to prevent infection from mold or bacteria. Peppermint oil is not recommended, and constant water filling or use during naps is unnecessary.
A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, 'How will this medication help me?' How should the nurse respond?
- A. This medication will treat your sleep apnea.
- B. This sedative will help you to sleep at night.
- C. This medication will treat your daytime restlessness.
- D. This analgesic will increase comfort while you sleep.
Correct Answer: C
Rationale: Modafinil is used to promote wakefulness in clients with narcolepsy or daytime sleepiness related to sleep apnea, addressing excessive daytime restlessness.
A nurse assesses a client who reports waking up, feeling very tired, even after 4 hours of good sleep. Which action should the nurse take first?
- A. Assess for sleep apnea.
- B. Refer to a sleep specialist.
- C. Review the client's medication list.
- D. Encourage increased sleep duration.
Correct Answer: A
Rationale: The client's symptoms suggest possible sleep apnea, which can cause fatigue despite adequate sleep duration. Assessing for sleep apnea is the priority to identify the underlying cause and guide further management.