Nokea
The nurse is providing discharge instructions for a patient with a total laryngectomy. Which of the following patient statements indicate that additional instruction is required?
- A. I must keep the stoma covered with a loose sterile dressing at all times.
- B. I can participate in most of my prior fitness activities except swimming.
- C. I should wear a Medic Alert bracelet that identifies me as a neck breather.
- D. I need to be sure that I have smoke and carbon monoxide detectors installed.
Correct Answer: A
Rationale: The stoma may be covered with clothing or a loose dressing, but this is not essential. The other patient comments are all accurate and indicate that the teaching has been effective.
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The nurse is caring for a patient who had a total laryngectomy and has a nursing diagnosis of hopelessness related to loss of control of personal care. Which of the following information obtained by the nurse is the best indicator that the problem identified in this nursing diagnosis is resolving?
- A. The patient lets the spouse provide tracheostomy care.
- B. The patient allows the nurse to suction the tracheostomy.
- C. The patient asks how to clean the tracheostomy stoma and tube.
- D. The patient uses a communication board to request 'No Visitors.'
Correct Answer: C
Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of self-care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.
The nurse is teaching a patient with allergic rhinitis about management of the condition. Which of the following information should the nurse include in the teaching plan?
- A. Over-the-counter (OTC) antihistamines cause sedation, so prescription antihistamines are usually ordered.
- B. Corticosteroid nasal sprays will reduce inflammation, but systemic effects limit their use
- C. Use of oral antihistamines for a few weeks before the allergy season may prevent reactions.
- D. Identification and avoidance of environmental triggers are the best ways to avoid symptoms.
Correct Answer: D
Rationale: The most important intervention is to assist the patient in identifying and avoiding potential allergens. Intranasal corticosteroids (not oral antihistamines) should be started several weeks before the allergy season. Corticosteroid nasal sprays have minimal systemic absorption. Nonsedating antihistamines are available OTC.
The nurse is obtaining a health history from a patient with a 40 year, pack a day smoking history, symptoms of hoarseness and tightness in the throat, and difficulty swallowing. Which of the following questions is most important for the nurse to ask?
- A. How much alcohol do you drink in an average week?
- B. Do you have a family history of head or neck cancer?
- C. Have you had frequent streptococcal throat infections?
- D. Do you use antihistamines for upper airway congestion?
Correct Answer: A
Rationale: Prolonged alcohol use and smoking are associated with the development of laryngeal cancer, which the patient's symptoms and history suggest. Family history is not a risk factor for head or neck cancer. Frequent antihistamine use would be asked about if the nurse suspected allergic rhinitis, but the patient's symptoms are not suggestive of this diagnosis. Streptococcal throat infections also may cause these clinical manifestations, but patients also will complain of pain and fever.
The nurse is teaching a patient with laryngeal cancer about radiation therapy. Which of the following patient statements indicate that the teaching has been effective?
- A. I will need to buy a water bottle to carry with me.
- B. I should not use any lotions on my neck and throat.
- C. Until the radiation is complete, I may have diarrhea.
- D. Alcohol-based mouthwashes will help clean oral ulcers.
Correct Answer: A
Rationale: Xerostomia can be partially alleviated by drinking fluids at frequent intervals. Radiation will damage tissues at the site being radiated but should not affect the abdominal organs, so loose stools are not a usual complication of head and neck radiation therapy. Frequent oral rinsing with non-alcohol-based rinses is recommended. Prescribed lotions and sunscreen may be used on irradiated skin, although they should not be used just before the radiation therapy.
The nurse is caring for a patient who has had an anterior packing for severe epistaxis. Which of the following nursing interventions should be included in the plan of care?
- A. Educate the patient to return in 3 days to have the nasal packing removed.
- B. Reassure the patient that the nose will look normal when the swelling subsides.
- C. Instruct the patient to keep the head elevated for 48 hours to minimize pain
- D. Teach the patient to use nonsteroidal anti-inflammatory drugs (NSAIDS) for pain control.
Correct Answer: A
Rationale: The patient should be instructed to return in 48-72 hours to have the anterior packing removed. Maintaining the head in an elevated position is not required. NSAIDs increase the risk for bleeding and should not be used. Although return to a preinjury appearance is the goal, it is not always possible to achieve this result and the nurse should not provide false reassurance.