Nokea
The nurse is providing suggestions to a client diagnosed with the effects of coryza. Which home remedy is appropriate when combined with medical treatment for pharyngitis?
- A. Cool mist humidifier
- B. Lavender scent
- C. Ice chips
- D. Salt water gargle
Correct Answer: D
Rationale: A salt water or saline gargle combines moisture from the water with sodium from the salt to aid in discomfort. Humidification and ice chips are also acceptable but just aids in soothing moisture to the air aiding in discomfort. A lavender scent isrelaxing but is not specifically a treatment appropriate to the condition described.
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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 initiates the following intervention upon receiving a client back to the clinical unit after a throat-related procedure, 'Elevate the head of the bed 45 degrees.' This assists in meeting which nursing goal?
- A. The client will have decreased pain.
- B. The client will remain alert and oriented.
- C. The client will have decreased edema.
- D. The client will have increased tissue perfusion.
Correct Answer: C
Rationale: Elevating the head of the bed 45 degrees when the client is fully awake decreases surgical edema and increases lung expansion. At this point in the recovery, elevating the head of the bed will not decrease the surgical pain as pain medication will be needed. Elevating the head of the bed will not affect mentation nor increase theblood supply.
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.
A nurse is evaluating teaching when discussing care of a new tracheostomy. Which statement, made by the client, indicates that the client does not accept the new tracheostomy?
- A. I must carry tissues with me.
- B. I must give up my love of pool aerobics.
- C. I will not be able to have the tracheostomy removed.
- D. Tell my spouse about it, I do not want to touch it.
Correct Answer: D
Rationale: Not wanting to participate in care and diverting the care to others indicates that the client has not accepted the tracheostomy. When evaluating teaching, the nurse should assess client and caregiver ability to provide home care. It is correct to carry tissues with the client because new tracheostomy tubes produce much mucous due to the irritation of the tube in the throat. Consideration needs to be arranged but being in a swimming pool may be completed as long as water does not surround the new tracheostomy. Stating the reality of not being able to remove the tracheostomy provides data that the client is accepting the tracheostomy as part of life.
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.