Nokea
The nurse in the walk-in clinic obtains a history of an upper respiratory infection with a red, sore throat. The client has been febrile for 3 days. Which nursing assessment should be stressed?
- A. Lung fields
- B. Voiding
- C. Joint pain
- D. Mentation
Correct Answer: B
Rationale: A pharyngitis occurs from inflammation of the throat, typically from a virus or bacteria. The most serious bacteria are the group A streptococci, commonly referred to as strep throat. Strep throat can have serious cardiac and renal complications,including sepsis. Assessing voiding can be an indication of renal status. Lung fields, joint pain, and mentation are completed in the head-to-toe assessment.
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The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
- A. Incrusted mucous membranes
- B. Hardened secretions
- C. Erosion of the trachea
- D. Noisy breathing
Correct Answer: D
Rationale: Enlarged adenoids may produce nasal obstruction, noisy breathing, snoring, and a nasal quality to the voice. Incrustation of the mucous membranes in the trachea and the main bronchus occurs during the postoperative period following atracheostomy. The long-term and short-term complications of tracheostomy include airway obstruction. These are caused by hardened secretions and erosion of the trachea.
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
- A. Epistaxis, twice last week
- B. Aphonia following a football game
- C. Hoarseness for 2 weeks
- D. Laryngitis following a cold
Correct Answer: C
Rationale: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
- A. Administer an over-the-counter decongestant.
- B. Use an anti-allergy medication to decrease rhinitis.
- C. Place a warm cloth over the sinus area of the forehead.
- D. Gently blow the nose to eliminate nasal secretions.
Correct Answer: A
Rationale: The principle causes of sinusitis are the spread of infection from the nasal passages to the sinus and the blockage of normal sinus drainage. Interference with sinus drainage predisposes a client to sinusitis. Administering a decongestant opensthe nasal passages for drainage. The other options can be helpful for a sinus infection, but opening the passages is best.
The nurse is providing discharge instructions to a client diagnosed with postoperative tonsillectomy and adenoidectomy. Which discharge instruction(s) would the nurse include? Select all that apply.
- A. Postoperative bleeding most frequently occurs in the hours after surgery.
- B. Avoid carbonated fluids
- C. Gradually increase fluids then add soft foods.
- D. Apply an ice collar to the neck area.
- E. Gargle with warm saline water.
- F. Limit pain medications to the nighttime.
Correct Answer: B,C,D,E
Rationale: A client may be at risk for postoperative bleeding for several days following the surgical procedure as the scab may be removed from the surgical site early causing the bleeding. Clients should avoid carbonated beverages and citrus fluids or foods because these agents are caustic to the suture line. The client should gradually increase fluids from thin liquids to thick liquids then soft foods through the recovery process. Applying an ice collar and gargling with saline decreases swelling and aids in preventing infection. Pain medication would be appropriate throughout the day, not just at night.
A client recently diagnosed with laryngeal cancer and awaiting a laryngectomy was encouraged to attend a support group prior to surgery. The client asked the nurse about the name of the laryngeal speech method where the client speaks with theassistance of a surgically implanted device. The nurse is correct to provide teaching on which method?
- A. Esophageal speech
- B. An artificial larynx
- C. A tracheoesophageal puncture
- D. An electronic voice box
Correct Answer: C
Rationale: A tracheoesophageal puncture is the method where a client speaks with the assistance of a surgically implanted valve that diverts air through the esophagus through a surgical opening in the posterior wall of the trachea with the assistance of a voice prosthesis. Esophageal speech occurs from swallowing air and forming words with the lips. An artificial larynx is a throat vibrator or an apparatus that projectssound into the oral cavity. There is no available electronic voice box.