Test Bank for Concepts of Care for Patients With Non-infectious Upper Respiratory problems
Test Bank for Concepts of Care for Patients With Non-infectious Upper Respiratory problems
Test Bank for Concepts of Care for Patients With Non-infectious Upper Respiratory problems
Test Bank for Concepts ...
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the
nurse perform first?
a. Facial pain
b. Vital signs
c. Bone displacement
d. Airway patency
ANS: D
A patent airway is the priority. The nurse first would make sure that the airway is patent and
then would determine whether the client is in pain and whether bone displacement or blood
loss has occurred.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
2. A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a
headache, and difficulty with vision. What action would the nurse take next?
a. Collect the nasal drainage on a piece of filter paper.
b. Encourage the client to blow his or her nose.
GRADESLAB.COM
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.
ANS: A
The client with nasal drainage after facial trauma could have a skull fracture resulting in
leakage of cerebrospinal fluid (CSF). CSF can be differentiated from regular drainage by the
fact that it forms a halo when dripped on filter paper and tests positive for glucose. The other
actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak
would increase the patient’s risk for infection.
3. A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the
nurse teach the client to prevent aspiration?
a. Tilt the head back as far as possible when swallowing.
b. Swallow twice while bearing down.
c. Breathe slowly and deeply while swallowing.
d. Keep the head very still and straight while swallowing.
ANS: B
This study source was downloaded by 100000844744134 from CourseHero.com on 04-13-2022 05:38:42 GMT -05:00
, Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or speech
language pathologist teaches the client the supraglottic method of swallowing. This includes
placing a small amount of food in the mouth, performing the Valsalva maneuver, then
swallowing twice. The client sits upright. The client holds the breath while swallowing twice.
Keeping the head still and straight will not decrease the risk of aspiration.
4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for
development of obstructive sleep apnea?
a. A 26-year-old woman who is 8 months pregnant.
b. A 42-year-old man with gastroesophageal reflux disease.
c. A 55-year-old woman who is 50 lb (23 kg) overweight.
d. A 73-year-old man with type 2 diabetes mellitus.
ANS: C
The client at highest risk would be the one who is extremely overweight. None of the other
clients have risk factors for sleep apnea. Clients with sleep apnea may develop
gastroesophageal reflux.
5. A nurse cares for a client who has hypertension that has not responded well to several
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medications. The client states compliance B.C anOissue.
M What action would the nurse take
next?
a. Assess the client for obstructive sleep apnea.
b. Arrange a home sleep apnea test.
c. Encourage the client to begin exercising.
d. Schedule a polysomnography
ANS: A
Hypertension not responding to medications can be a sign of obstructive sleep apnea (OSA).
The nurse would assess the client using an evidence-based tool, such as the STOP-Bang Sleep
Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, and
the Multiple Sleep Latency Test. If the results of the assessment indicate OSA may be a
problem, the nurse would consult the primary health care provider for further testing. An
at-home sleep-study is often done prior to a polysomnography. Excessive weight can
contribute to OSA so exercising is always encouraged, but this is not specific to assessing for
OSA.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Obstructive sleep apnea, Nursing assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control
6. A nurse cares for a client after radiation therapy for neck cancer. The client reports extreme
dry mouth. What action by the nurse is most appropriate?
a. Ask the client to gargle with mouthwash containing lidocaine.
This study source was downloaded by 100000844744134 from CourseHero.com on 04-13-2022 05:38:42 GMT -05:00
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