Pierce College » Nursing » Nursing 406 - Adult Health Care » Spring 2020

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Question #1

A client seeks care for hoarseness that has lasted for 1 month. To elicit the most appropriate information about this problem, the nurse should ask which question?

A. "Do you eat spicy foods?"

B. "Do you eat a lot of red meat?"

C. "Do you smoke cigarettes, cigars, or a pipe?"

D. "Have you strained your voice recently?"

Question #2

A client comes into the Emergency Department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

A. Apply a moustache dressing.

B. Provide a nasal splint.

C. Apply direct continuous pressure.

D. Place the client in a semi-Fowler's position.

Question #3

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

A. Provide meticulous mouth care every 4 hours.

B. Encourage deep breathing every 2 hours.

C. Caution against frequent coughing.

D. Monitor for signs of dysphagia.

Question #4

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube?

A. "The ET tube will be inserted through an opening in your trachea."

B. "The ET tube will be connected to a negative-pressure ventilator."

C. "The ET tube will remain in place for at least a day postsurgery."

D. "The ET tube will maintain your airway while you're under anesthesia."

Question #5

Wound drains, inserted during the laryngectomy, stay in place until what criteria are met?

A. Drainage is <30 mL/day for 2 consecutive days.

B. The surgical site is dry with encrustations.

C. The patient is able to assist with his own suctioning.

D. The stoma is healed, about 6 weeks after surgery.

Question #6

The nurse assesses a client who is bleeding profusely from the nose. The nurse documents this finding as which condition?

A. Epistaxis

B. Rhinorrhea

C. Xerostomia

D. Dysphagia

Question #7

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

A. Makes a fist with one hand with the thumb outside the fist

B. Stands behind the worker, who has hands across the neck

C. Places both arms around the worker's waist

D. Exerts pressure against the worker's abdomen

Question #8

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect?

A. Post operative bleeding

B. Edema of the upper airway

C. Infection

D. Plugged tracheostomy tube

Question #9

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?

A. Epistaxis, twice last week

B. Laryngitis following a cold

C. Hoarseness for 2 weeks

D. Aphonia following a football game

Question #10

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of

A. 2 to 12 days

B. 1 to 3 months

C. 3 to 6 months

D. 20 to 30 days

Question #11

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

A. An antibiotic such as amoxicillin

B. An ointment such as bacitracin

C. An antihistamine such as Benadryl

D. An antiviral agent such as acyclovir

Question #12

The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.),,

A. Try a liquid or soft diet during the acute stage of the disease.

B. Stay on bed rest during the febrile stage of the illness.

C. Apply an ice collar.

D. Drink warm or hot liquids during the acute stage of the disease.

E. Gargle with an alcohol-based mouthwash.

Question #13

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

A. Bleeding

B. Difficulty swallowing

C. Difficulty talking

D. Throat pain

Question #14

A client exhibits a sudden and complete loss of voice and is coughing. The nurse states

A. "Do not smoke and avoid being around others who are smoking."

B. "The 'tickle' in your throat will improve with cold liquids."

C. "It is fine to speak in a whisper. This does not strain your voice."

D. "Do not use a humidifier; it will make your problem worse."

Question #15

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

A. It requires the insertion of a prosthesis into the trachea.

B. It enables the client to form words with the lips.

C. It will result in a low, gruff-sounding voice.

D. It requires the client to hold a throat vibrator against the neck.

Question #16

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

A. Develop an alternate method of communication.

B. Encourage oral nutrition on the second postoperative day.

C. Assess the tracheostomy cuff for leaks.

D. Maintain the client in a low-Fowler’s position.

Question #17

The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?

A. When the patient has less than 30 mL for 2 consecutive days

B. When the drainage tube comes out

C. When the patient states that there is discomfort and requests removal

D. In 1 week when the patient no longer has serous drainage

Question #18

The nurse advises a patient who sustained a fractured nose during an automobile accident that surgery will be necessary. Due to significant facial edema, surgery would be scheduled:

A. Within 1 week.

B. After 1 month.

C. Within 24 hours.

D. In 2 to 3 weeks.

Question #19

A nurse takes the initial history of a patient who is being examined for cancer of the larynx. Select the sign that is considered an early clinical indicator.

A. Persistent ulceration

B. Cervical lymph adenopathy

C. Hoarseness of more than 2 week's duration

D. Dysphasia

Question #20

A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:

A. One vocal cord was removed along with a portion of the larynx.

B. A portion of the vocal cord was removed.

C. A permanent tracheal stoma would be necessary.

D. The voice was spared and a tracheostomy would be in place until the airway was established.

Question #21

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

A. "Clean the tracheostomy tube with alcohol and water."

B. "Family members should continue to talk to the client."

C. "Limit the amount of protein in the diet."

D. "Oral intake of fluids should be limited for 1 week only."

Question #22

When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?

A. Hand-held showers

B. Wearing a scarf over the stoma

C. Swimming

D. Coughing

Question #23

A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by

A. Placing the client prone with the head turned to the side

B. Sitting the client in the semi–Fowler's position

C. Maintaining a warm compress around the client's neck area

D. Removing the oral airway before the gag reflex has returned for client comfort

Question #24

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is

A. Ineffective airway clearance related to excess mucus production

B. Acute pain related to upper airway irritation

C. Deficient fluid volume related to increased fluid needs

D. Deficient knowledge related to prevention of upper respiratory infections

Question #25

The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?

A. Erosion of the trachea

B. Incrusted mucous membranes

C. Noisy breathing

D. Hardened secretions

Question #26

The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?

A. Partial laryngectomy

B. Total laryngectomy

C. Laser surgery

D. Radiation therapy

Question #27

Your client is status post total laryngectomy and cannot talk. What intervention should you make to help this client communicate?

A. Teach the client esophageal speech.

B. Provide alternative methods of communication.

C. Provide a lip reader as a translator.

D. Teach the client about an artificial larynx.

Question #28

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

A. Monitor heart rhythm.

B. Assess capillary refill.

C. Obtain vital signs.

D. Auscultate lung sounds.

Question #29

The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client’s care?

A. Position the patient in the side-lying position.

B. Apply pressure to the convex of the nose.

C. Restrict fluid intake.

D. Apply an ice pack.

Question #30

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

A. Applying nasal packing

B. Applying steroidal nasal spray

C. Preparing the patient for a septoplasty

D. Administering nasal lavage

Question #31

Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?

A. Apply pressure to the convex portion of the nose

B. Apply a warm pack postoperatively

C. Provide a splint postoperatively

D. Ensure mouth breathing

Question #32

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

A. Headache

B. Fever

C. Nausea

D. Myalgias

Question #33

Your client has a history of hoarseness lasting longer than 2 weeks. The client is now complaining of feeling a lump in their throat. What would you suspect this client has?

A. Laryngeal cancer

B. Cancer of the tonsils

C. Laryngeal polyps

D. Cancer of the pharynx

Question #34

The nurse is caring for a client status post adenoidectomy. The nurse finds the client in severe respiratory distress when entering the room. What does the nurse suspect?

A. Postoperative bleeding

B. Infection

C. Edema of the upper airway

D. Plugged tracheostomy tube

Question #35

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

A. “I used my voice in excess over the weekend.”

B. “I have environmental allergies.”

C. “I was chewing ice chips all day long.”

D. “I smoke a pack of cigarettes a day.”

Question #36

A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse’s priority intervention?

A. Prepare for immediate tracheostomy.

B. Prepare to administer subcutaneous epinephrine and corticosteroids.

C. Prepare for endotracheal intubation with mechanical ventilation.

D. Apply 100% oxygen via a face mask.

Question #37

A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?

A. Clarithromycin

B. Cephalexin

C. Cefuroxime

D. Amoxicillin-clavulanic acid

Question #38

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:

A. lie supine with his neck extended.

B. hold his nose while bending forward at the waist.

C. sit upright, leaning slightly forward.

D. blow his nose and then put lateral pressure on his nose.

Question #39

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

A. Ineffective airway clearance

B. Impaired verbal communication

C. Imbalanced nutrition: Less than body requirements

D. Anxiety and depression

Question #40

A client has acute bacterial rhinosinusitis for several weeks despite treatment. The nurse observes for a possible complication of the infection by assessing for

A. Hypertension

B. Mild headache

C. Nausea

D. Nuchal rigidity

Question #41

A client comes into the clinic complaining of hoarseness that has lasted for about a month. What would you suspect?

A. Laryngeal cancer

B. Chronic tonsilittis

C. Chronic pharyngitis

D. Laryngeal polyps

Question #42

A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?

A. Partial laryngectomy

B. Total laryngectomy

C. Hemilaryngectomy

D. Supraglottic laryngectomy

Question #43

A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?

A. headaches in the morning

B. a feeling of swelling at the back of the throat

C. discomfort when drinking cold liquids

D. weight loss

Question #44

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client’s room?

A. A nasal cannula

B. A ventilator

C. A rigid shell

D. A face mask

Question #45

The nurse is caring for a client diagnosed with rhinosinusitis. The physician has ordered the client to receive four sprays of budesonide (Rhinocort) in each nostril every morning. The nurse informs the client that a common side effect of this medication is

A. Arthralgia

B. Epistaxis

C. Headache

D. Watery eyes

Question #46

The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?

A. “After surgery you will have a sore throat, but you will be able to speak.”

B. “You can use writing or a communication board to communicate.”

C. “After surgery you will have to use an electric larynx to communicate.”

D. “A speech therapist will evaluate you and recommend a system of communication after surgery.”

Question #47

A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?

A. Staphylococcus aureus

B. Gram-negative Klebsiella

C. Pseudomonas aeruginosa

D. Group A, beta-hemolytic streptococcus

Question #48

Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?

A. Offer plenty of thin liquids when intake resumes

B. Season food to suit an increased sense of taste and smell

C. Use enteral feedings after the procedure

D. Recommend the long-term use of zinc lozenges

Question #49

Which clinical manifestation of hemorrhage is related to carotid artery rupture?

A. Shallow respirations

B. Increased pulse rate

C. Increased blood pressure

D. Dry skin

Question #50

A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to

A. Wait 10 seconds before administering the second spray.

B. Clean the medication container once each day.

C. Tilt the head back when activating the spray of the medication.

D. Blow the nose before applying medication into the nares.

Question #51

A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to

A. Report relief of pain to level 3 using a pain intensity scale of 1 to 10.

B. Take acetaminophen with codeine when pain is 5 or above.

C. Use a pain intensity rating scale of 0 to 10.

D. Gargle with a warm saline solution frequently.

Question #52

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have

A. difficulty swallowing foods"

B. a persistent cough or sore throat"

C. trouble with your breathing"

D. a foul odor to your breath"

Question #53

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. Magnetic resonance imaging (MRI)

C. Nasal culture

D. Transillumination of the sinus

Question #54

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

A. Assess the tracheostomy cuff for leaks.

B. Develop an alternate method of communication.

C. Maintain the client in a low-Fowler’s position.

D. Encourage oral nutrition on the second postoperative day.

Question #55

A 76-year-old client presents to the ED reporting “laryngitis.” The triage nurse should ask whether the client has a medical history that includes

A. Chronic obstructive pulmonary disease (COPD)

B. Congestive heart failure (CHF)

C. Respiratory failure (RF)

D. Gastroesophageal reflux disease (GERD)

Question #56

A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?

A. Gram-negative Klebsiella

B. Pseudomonas aeruginosa

C. Group A, beta-hemolytic streptococci

D. Staphylococcus aureus

Question #57

As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:

A. inhaling polluted air isn't a risk factor for laryngeal cancer.

B. laryngeal cancer occurs primarily in women.

C. laryngeal cancer is one of the most preventable types of cancer.

D. adenocarcinoma accounts for most cases of laryngeal cancer.

Question #58

When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?

A. Contact the physician.

B. Look for a halo sign after the drainage dries.

C. Have the client blow his nose.

D. Test the nasal drainage for glucose.

Question #59

A late complication of radiation therapy is

A. pain.

B. xerostomia.

C. dysphasia.

D. laryngeal necrosis.

Question #60

A client is being discharged from an outpatient surgery center following a tonsillectomy. What instruction should the nurse give to the client?

A. "Decrease oral intake if increased swallowing occurs."

B. "You may have a sore throat for 1 week."

C. "You are allowed to have hot tea or coffee."

D. "Gargle with a warm salt solution."

Question #61

A client is in the emergency department following a fall on the face. The client reports facial pain. The nurse assesses bleeding from nasal cuts and from the nares, a deformity to the nose, periorbital ecchymoses, and some clear fluid draining from the right nostril. The first action of the nurse is to

A. Check the clear fluid for glucose.

B. Apply an ice pack to the nose.

C. Reassure the client that the nose is not fractured.

D. Administer prescribed oral ibuprofen (Motrin).

Question #62

Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?

A. Decreased pulse rate

B. Increased blood pressure

C. Warm, moist skin

D. Rapid, deep respirations

Question #63

The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?

A. It will result in a low, gruff-sounding voice.

B. It enables the client to form words with the lips.

C. It requires the insertion of a prosthesis into the trachea.

D. It requires the client to hold a throat vibrator against the neck.

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Nursing 406 - Adult Health Care » Spring 2020 » Chapter 22 Quiz

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