Nokea
The nurse is caring for the client who presents to the clinic with hoarseness for 2 months. Further testing diagnoses laryngeal cancer with the treatment plan of a radical neck dissection. When reinforcing information provided by the physician, which nursing instruction is most correct?
- A. Laser surgery is a possibility with limited side effects.
- B. The physician removes lymph nodes, muscles and tissue.
- C. Once the tissue is removed, no further treatment is necessary.
- D. The client will be able to speak normally once the swelling subsides.
Correct Answer: B
Rationale: When the physician prescribes a radical neck dissection, the disease has extended beyond the larynx. The physician removes lymph nodes, muscle, and tissue. Laser surgery is completed for early lesions and does not have the ability to remove all of the structure needed. Chemotherapy and radiation is typically administered. Theclient will lose the ability to speak normally.
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The nurse is caring for a client in the physician's office with a potential sinus infection. The physician orders a diagnostic test to identify if fluid is found in the sinus cavity. Which diagnostic test, written by the physician, is specifically ordered for this purpose?
- A. CBC with differential
- B. Transillumination of the sinus
- C. Nasal culture
- D. Magnetic resonance imaging (MRI)
Correct Answer: B
Rationale: Transillumination and $x$-rays of the sinuses may show a change in the shape of or confirms that there is fluid in the sinus cavity. CBC with differential can note an elevated white blood cell count but not confirm fluid in the sinus cavity. A nasal culture can note bacteria in the nares. An MRI is an expensive procedure which is not typically prescribed for a potential infection and not specifically ordered to identify fluid in thesinus cavity.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
- A. A ventilator
- B. A face mask
- C. A rigid shell
- D. A nasal cannula
Correct Answer: B
Rationale: A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
- A. Copious mucous secretions
- B. Sudden restlessness
- C. Harsh cough
- D. Bilateral breath sounds present
Correct Answer: B
Rationale: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube.Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.
The nurse is an occupational health nurse who is presenting a workshop on laryngeal cancer. What risk factor(s) would the nurse be sure to include in the workshop? Select all that apply.
- A. Alcohol
- B. Age
- C. Tobacco
- D. Industrial pollutants
- E. Region of country lived in
Correct Answer: A,B,C,D
Rationale: Carcinogens, such as tobacco, alcobol, and industrial pollutants, are associated with laryngeal cancer. The age of the client is also a factor, with a higher incidence among those 65 years of age or older. Region of country lived in is notassociated with laryngeal cancer as a specific risk factor.
The nurse is caring for a client with an upper respiratory disorder. The client states they have a hacky, nonproductive cough, which wakens them during the night. Which over-the-counter medication would the nurse suggest to diminish the cough during the night?
- A. Diphenhydramine
- B. Dextromethorphan
- C. Pseudoephedrine
- D. Fluticasone
Correct Answer: B
Rationale: Dextromethorphan acts on the central nervous system to raise the cough threshold and dampen the cough reflex. Diphenhydramine is an antihistamine that relieves symptoms associated with allergies. Pseudoephedrine relieves nasalcongestion associated with sinusitis, colds, and allergies. Fluticasone reduces tissue edema.