Nokea
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.
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A patient comes to the ED and is admitted with epistaxis. Pressure has been applied to the patients midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using what treatment to control the bleeding?
- A. Irrigation with a hypertonic solution
- B. Nasopharyngeal suction
- C. Normal saline application
- D. Silver nitrate application
Correct Answer: D
Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis.
It is cold season and the school nurse has been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?
- A. Pharyngitis is more common in children whose immunizations are not up to date.
- B. There are no effective, evidence-based treatments for pharyngitis.
- C. Use of warm saline gargles or throat irrigations can relieve symptoms.
- D. Heat may increase the spasms in pharyngeal muscles.
Correct Answer: C
Rationale: Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. The benefits of this treatment depend on the degree of heat that is applied. The nurse teaches about these procedures and about the recommended temperature of the solution: high enough to be effective and as warm as the patient can tolerate, usually 105°F to 110°F (40.6°C to 43.3°C). Irrigating the throat may reduce spasm in the pharyngeal muscles and relieve soreness of the throat. You would not tell the parent teacher organization that there is no real treatment of pharyngitis.
A 42-year-old patient is admitted to the ED after an assault. The patient received blunt trauma to the face and has a suspected nasal fracture. Which of the following interventions should the nurse perform?
- A. Administer nasal spray and apply an occlusive dressing to the patients face.
- B. Position the patients head in a dependent position.
- C. Irrigate the patients nose with warm tap water.
- D. Apply ice and keep the patients head elevated.
Correct Answer: D
Rationale: Immediately after the fracture, the nurse applies ice and encourages the patient to keep the head elevated. The nurse instructs the patient to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used.
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.
A patient has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the patient asks, Does this kind of cancer tend to spread to other parts of the body? What is the nurses best response?
- A. In many cases, this type of cancer spreads to other parts of the body.
- B. This cancer usually does not spread to distant sites in the body.
- C. You will have to speak to your oncologist about that.
- D. Squamous cell carcinoma is nothing to be concerned about, so try to focus on your health.
Correct Answer: B
Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The patients prognosis is determined by the oncologist, but the patient has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the patients concerns.