ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 20 : Caring for Clients With Upper Respiratory Disorders Questions
Question 1 of 5
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?
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.
Question 2 of 5
The nurse is obtaining a health history from a client on an annual physical exam. Which documentation should be brought to the physician's attention?
Correct Answer: C
Rationale: Persistent hoarseness, especially of unknown cause, can be a sign of laryngeal cancer and merits prompt investigation. Epistaxis can be from several causes and has occurred infrequently. Aphonia and laryngitis are common following the noted activity.
Question 3 of 5
The emergency department nurse is assessing a client following a motor vehicle accident. The nurse notes facial deformities with swelling and bleeding and a clear drainage coming from the nares. Which diagnostic test is completed to determine if the clear drainage is cerebrospinal fluid?
Correct Answer: C
Rationale: When clear drainage is observed from the nares of a client, a Dextrostix is used to determine the presence of glucose which is present in cerebrospinal fluid. A serum CBC would provide information on red and white blood cell count. A low red blood cell count is may be found due to hemorrhage that has occurred. Nitrazine paper is under to assess vaginal secretions for the presence of amniotic fluid. A glucometercheck will provide information on serum glucose, not the glucose level in the cerebrospinal fluid.
Question 4 of 5
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?
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.
Question 5 of 5
The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?
Correct Answer: A
Rationale: The client with a total laryngectomy is not able to speak. Communication needs to be established using an alternate method. The client typically has difficulty with swallowing due to edema in the immediate postoperative period. Alternate forms of nutrition are used. The tracheostomy cuff is often deflated for periods of time. The head of the bed is maintained in a semi-Fowler's position to decrease edema.