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 is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
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.
Question 2 of 5
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?
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.
Question 3 of 5
The nurse is caring for a client diagnosed with coryza possibly from the rhinovirus. Vital signs are temperature: $101.2^{\circ} \mathrm{F}$, pulse: 72 beats/minute, respirations: 28 breaths/minute, blood pressure: $112 / 70$ $\mathrm{mm} \mathrm{Hg}$. Upon morning assessment, the client states a sore throat, moist cough, and watery eyes. The lungs are coarse in the bases. Which afternoon assessment finding suggests the advancement to an infectious process?
Correct Answer: C
Rationale: Coryza refers to the common cold many times associated with a virus such as the rhinovirus. The nurse notes that the client is currently febrile. A rise in the temperature is interpreted that the client continues to have a sustained elevated temperature which suggests a bacterial infection. All viruses can include symptoms of achiness, headache, and an increase in the respiratory rate. Increased respiratory rate does not always indicate infection because it can be a sign of a multitude of other problems.
Question 4 of 5
The nurse is caring for a client in a physician's office whose $x$-ray of the sinus reveals exudate in the maxillary sinus. Which equipment must the nurse have present in the room?
Correct Answer: C
Rationale: The nurse would have sinus irrigation equipment available for the physician as saline irrigation of the maxillary sinus is done to remove exudate and promote drainage and avoid infection. An otoscope and tuning fork may be present in the room for further assessment. An ophthalmoscope is typically not needed.
Question 5 of 5
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?
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.