Nokea
The nurse is performing an assessment on a patient who has been diagnosed with cancer of the larynx. Part of the nurses assessment addresses the patients general state of nutrition. Which laboratory values would be assessed when determining the nutritional status of the patient?
- A. White blood cell count
- B. Protein level
- C. Albumin level
- D. Platelet count
- E. Glucose level
Correct Answer: B,C,E
Rationale: The nurse also assesses the patients general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the patients nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the patients nutritional status.
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A patient is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the patients nutrition during treatment?
- A. A 1.5 L/day fluid restriction
- B. A high-potassium, low-sodium diet
- C. A liquid or soft diet
- D. A high-protein diet
Correct Answer: C
Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the patients appetite and the degree of discomfort that occurs with swallowing. The patient is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.
The nurse is creating a care plan for a patient who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. What form of alaryngeal communication will likely be chosen?
- A. Esophageal speech
- B. Electric larynx
- C. Tracheoesophageal puncture
- D. American sign language (ASL)
Correct Answer: C
Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, and electric larynx or ASL.
The nurse is caring for a patient who needs education on his medication therapy for allergic rhinitis. The patient is to take cromolyn (Nasalcrom) daily. In providing education for this patient, how should the nurse describe the action of the medication?
- A. It inhibits the release of histamine and other chemicals.
- B. It inhibits the action of proton pumps.
- C. It inhibits the action of the sodium-potassium pump in the nasal epithelium.
- D. It causes bronchodilation and relaxes smooth muscle in the bronchi.
Correct Answer: A
Rationale: Cromolyn (Nasalcrom) inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-3-adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
- A. Facilitate total parenteral nutrition (TPN).
- B. Keep a complete suction setup at the bedside.
- C. Feed the patient several small meals daily.
- D. Refer the patient for occupational therapy.
Correct Answer: B
Rationale: Due to the risk for aspiration, the nurse keeps a suction setup available in the hospital and instructs the family to do so at home for use if needed. TPN is not indicated and small meals do not necessarily reduce the risk of aspiration. Physical therapists do not address swallowing ability.
The nurse is planning the care of a patient who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
- A. Anxiety related to diagnosis of cancer
- B. Altered nutrition related to swallowing difficulties
- C. Ineffective airway clearance related to airway alterations
- D. Impaired verbal communication related to removal of the larynx
Correct Answer: C
Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions due to the critical need to maintain a patent airway post-laryngectomy.