Chapter 26 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 26

Question 1

Type: MCSA

A patient tells the nurse he has a cold every spring that lasts for 8 to 10 weeks. The nurse suspects that the patient is experiencing which condition?

1. Acute viral rhinitis

2. Allergic rhinitis

3. Vasomotor rhinitis

4. Atrophic rhinitis

Correct Answer: 2

Rationale 1: Acute viral rhinitis is the common cold and should resolve within 7 to 10 days.

Rationale 2: Allergic rhinitis, or hay fever, results from a sensitivity reaction to allergens such as plant pollens. It tends to occur seasonally and lasts longer than a common cold.

Rationale 3: Causes of vasomotor rhinitis include cold air, strong odors, stress, and inhaled irritants. Symptoms resolve more quickly than several weeks.

Rationale 4: Atrophic rhinitis is characterized by changes in the mucous membrane of the nasal cavities. Symptoms resolve more quickly than several weeks.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 2

Type: MCSA

A patient says, My nose is always congested, and it just seems to get worse with the nasal spray Ive been using. The nurse realizes that this patient is describing which situation?

1. Incorrect administration of the nasal spray

2. An acute sinus infection that needs to be treated with antibiotics

3. Side effect of the nasal spray

4. Rebound nasal congestion

Correct Answer: 4

Rationale 1: There is no indication that the patient is not administering the nasal spray correctly.

Rationale 2: No other signs indicate that the patient has a bacterial sinus infection.

Rationale 3: The worsening nasal congestion is not considered a side effect of nasal spray.

Rationale 4: Chronic use of nasal sprays may lead to rhinitis medicamentosa, a rebound phenomenon of drug-induced nasal irritation and inflammation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 3

Type: MCSA

A patient being seen for a cough tells the nurse, After I leave here, I need to get to the dentist. My upper teeth are hurting and I dont know why. Which nursing action is indicated?

1. End the visit so the patient can get to the dentist.

2. Assess the patient for a sinus infection.

3. Reschedule the appointment for another time.

4. Tell the patient there is nothing wrong with his teeth.

Correct Answer: 2

Rationale 1: The patient has a medical need and is in a medical setting. It would not be appropriate to end the appointment.

Rationale 2: Manifestations of sinusitis include pain and tenderness across the infected sinuses, plus headache, fever, and malaise. The pain usually increases when the patient leans forward. When the maxillary sinuses are involved, pain and pressure are felt over the cheek. The pain may be referred to the upper teeth.

Rationale 3: The patient has a medical need and is in a medical setting. It would not be appropriate to reschedule the appointment.

Rationale 4: Until an assessment is performed and a diagnosis is made or ruled out, it would be incorrect to tell the patient that nothing is wrong.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-2

Question 4

Type: MCMA

The nurse suspects that a patient is demonstrating signs of tonsillitis. Which findings are indicative of this disorder?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Pain on swallowing

2. Thirst

3. Nuchal rigidity

4. Enlarged lymph nodes in the neck

5. Fever

Correct Answer: 1,4,5

Rationale 1: Odynophagia, or painful swallowing, is an indicator of tonsillitis.

Rationale 2: Thirst is not suggestive of tonsillitis.

Rationale 3: Nuchal rigidity (pain when bending the neck) is not suggestive of tonsillitis.

Rationale 4: Enlarged, tender lymph nodes in the neck are an indicator of infection, possibly in the tonsils.

Rationale 5: Fever is an indicator of infection, possibly in the tonsils.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-3

Question 5

Type: MCSA

A patient is receiving anterior nasal packing for a nosebleed. What should be included in the instructions for this patient?

1. Remove the packing in the morning.

2. The packing will stay in place for at least 5 days.

3. Return to the clinic tomorrow afternoon to have the packing removed.

4. The packing will be removed and new packing inserted in 2 days.

Correct Answer: 2

Rationale 1: Anterior nasal packs are usually left in place beyond the next morning.

Rationale 2: Anterior nasal packs are usually left in place for 5 days.

Rationale 3: Packing is usually left in place beyond the next day.

Rationale 4: Packing is not removed so that new packing can be inserted.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-1

Question 6

Type: MCSA

While engaging in a high school sports activity, an adolescent sustains an injury to the nose. Which finding indicates that the patient has a nasal fracture?

1. Shortness of breath

2. Diaphoresis

3. Drop in blood pressure

4. Periorbital ecchymosis

Correct Answer: 4

Rationale 1: Shortness of breath is not a typical response to nasal fracture.

Rationale 2: Diaphoresis is not a typical response to nasal fracture.

Rationale 3: A decrease in blood pressure is not a typical response to nasal fracture.

Rationale 4: Manifestations of a fractured nose include periorbital edema and ecchymosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-1

Question 7

Type: MCSA

While eating a meal in the hospital, a patient demonstrates difficulty breathing and signs of choking. The nurse realizes that the patient is experiencing which condition?

1. Laryngeal obstruction

2. Pulmonary emboli

3. Epiglottitis

4. An acute myocardial infarction

Correct Answer: 1

Rationale 1: The most common manifestations of laryngeal obstruction are coughing, choking, gagging, obvious difficulty breathing with use of accessory muscles, and inspiratory stridor.

Rationale 2: Pulmonary emboli would not likely be the cause of choking for this patient.

Rationale 3: Epiglottitis is an infection and is not described in this case.

Rationale 4: Acute myocardial infarction would not be the obvious diagnosis in this case.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-5

Question 8

Type: MCSA

The nurse observes a patients respirations during sleep and notes the absence of respirations for periods lasting from 15 to 45 seconds. This finding is consistent with which condition?

1. Laryngeal spasm

2. Sleep apnea

3. Respiratory acidosis

4. Renal failure

Correct Answer: 2

Rationale 1: No symptoms of laryngeal spasm are noted.

Rationale 2: Manifestations of obstructive sleep apnea include: loud, cyclic snoring; periods of apnea that lasts over 10 seconds during sleep; gasping or choking during sleep; restlessness and thrashing during sleep; daytime fatigue and sleepiness; morning headache; personality changes; depression; intellectual impairment; impotence; and hypertension.

Rationale 3: A diagnosis of respiratory acidosis requires laboratory evaluation.

Rationale 4: No symptoms of renal failure are described.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26-5

Question 9

Type: MCSA

A female patient is seen for increased hoarseness and a change in voice quality. There are no other symptoms. What is an appropriate assessment question for the nurse to ask this patient?

1. What medications are you currently taking?

2. Have you recently experienced a cold?

3. Have you recently visited another country?

4. What is your occupation?

Correct Answer: 4

Rationale 1: The list of medications is not likely to be relevant to this patients specific complaints.

Rationale 2: The patient with a cold would exhibit additional signs and symptoms.

Rationale 3: The recent travel history is not likely to be relevant to this patients specific complaints.

Rationale 4: Hoarseness and a breathy voice quality are manifestations of benign vocal cord tumors. In adults, vocal cord nodules are often referred to as singers nodules; cheerleaders and public speakers may also develop them. Voice abuse also contributes to the development of vocal cord polyps, as do cigarette smoking and chronic irritation from industrial pollutants. Assessment questions usually start with the causes that would be easiest to eliminate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-5

Question 10

Type: MCMA

A patient who is scheduled for a partial laryngectomy asks if he will still be able to talk after the surgery. What are appropriate nursing responses to this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. No, you will not.

2. You will have to ask your physician.

3. Yes, but it might sound a little different.

4. You will be able to talk, but with an electronic device.

5. Speech is usually preserved, but we will know better after surgery.

Correct Answer: 3,5

Rationale 1: The voice is generally preserved in partial laryngectomy.

Rationale 2: With an understanding of partial laryngectomy, the nurse is equipped to answer the question.

Rationale 3: The voice generally is well preserved, although it may be changed by the surgery.

Rationale 4: The use of an electronic device is generally not necessary following a partial laryngectomy.

Rationale 5: In a partial laryngectomy, speech is generally preserved.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-6

Question 11

Type: MCMA

The nurse is providing care to a patient with a new tracheostomy. Which intervention is appropriate to include in this patients care?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Do not remove tracheostomy ties.

2. Assess frequently to determine if sterile suctioning is needed.

3. Clean the inner cannula with sterile normal saline.

4. Remove crusted secretions with hydrogen peroxide and flush with normal saline.

5. Assess areas under the edges of the faceplate for breakdown.

Correct Answer: 2,4,5

Rationale 1: Tracheostomy ties may be removed and replaced.

Rationale 2: The patient may be unable to clear secretions and may require suctioning.

Rationale 3: The steps in tracheostomy care include removing the inner cannula for cleaning.

Rationale 4: The steps in tracheostomy care include using hydrogen peroxide to remove crusted secretions.

Rationale 5: Areas under the edges of the faceplate are prone to breakdown and should be assessed routinely.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-5

Question 12

Type: MCSA

While recovering at home from a total laryngectomy and neck dissection, a patient notices an increase in left shoulder weakness. This

symptom is consistent with which condition?

1. Normal recovery

2. Damage to the spinal accessory nerve

3. Side effect of neck radiation therapy

4. Medication complication

Correct Answer: 2

Rationale 1: Left shoulder weakness in not a normal finding for a post-laryngectomy patient.

Rationale 2: Left shoulder drop may result from damage to the spinal accessory nerve. This finding should be reported to the physician.

Rationale 3: There is no mention of radiation treatments.

Rationale 4: Medications are not mentioned in the history.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26-6

Question 13

Type: MCSA

The nurse reviews the patients clinic record and recognizes that priority teaching for this patient would include which information?

1. Antibiotics should be taken as directed until the prescription is finished.

2. It may be 4 weeks before your infection is cleared.

3. Gargle with hydrogen peroxide mixed with cool water.

4. Return to the clinic tomorrow for a flu immunization.

Correct Answer: 1

Rationale 1: The patient with streptococcal bacterial pharyngitis is given antibiotics and told to continue antibiotic therapy as directed until the prescription is finished.

Rationale 2: The infection should clear in a shorter period.

Rationale 3: The patient should be advised to gargle with warm salt water for comfort.

Rationale 4: There is no indication that the patient should receive influenza vaccine while experiencing these symptoms.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 14

Type: MCSA

The nurse observes a patient who is gagging and using this gesture (see illustration). What is the nurses response?

1. Assume the patient is having throat pain and administer pain medication.

2. Prepare to perform the Heimlich maneuver.

3. Assess the patient for cyanosis, difficulty breathing, and stridor and wait until normal breathing resumes.

4. Sit with the patient until the laryngospasm passes and encourage deep breathing.

Correct Answer: 2

Rationale 1: Assuming the patient is having throat pain is an inappropriate response.

Rationale 2: The patient who is gagging and using the universal gesture for choking likely has an airway obstruction. The goal is to maintain an open airway and clear the obstruction. If the obstruction is complete, the Heimlich maneuver is performed.

Rationale 3: Assessing the patient is inappropriate; choking constitutes a life-threatening situation.

Rationale 4: Sitting with the patient is inappropriate; choking constitutes a life-threatening situation.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-5

Question 15

Type: MCSA

A patient with nasal trauma has clear, watery fluid dripping from the nose. The nurse performs the halo test, which is positive. What does this positive result indicate?

1. A fracture of the ethmoid or sphenoid sinus

2. The need to suction the patient

3. The presence of cerebrospinal fluid (CSF)

4. A chyle leak

Correct Answer: 3

Rationale 1: The fractures involved may cause damage to the dura, but clear nasal drainage is not an indication of a fracture.

Rationale 2: Patients with nasal fracture should not be suctioned as this may introduce microorganisms and cause additional tissue trauma.

Rationale 3: In the halo test, fluid is allowed to drain onto a clean white dressing. If it forms a halo of red-tinged fluid, the test is positive for a CSF leak.

Rationale 4: Chyle leak is a postoperative complication of head and neck cancer.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26-1

Question 16

Type: MCSA

Which patient requires the most immediate intervention by the nurse?

1. A patient with a mandibular fracture who has facial numbness and tingling

2. A patient with a fractured nasal bone experiencing a nosebleed

3. A patient with a maxillary fracture who has been swallowing frequently

4. A patient with a temporal bone fracture experiencing hearing loss

Correct Answer: 3

Rationale 1: Numbness and tingling in the patient with a mandibular fracture are expected and transient as the edema of the trigeminal facial nerves dissipates.

Rationale 2: This patient is not in as great a danger of hemorrhage as is another patient.

Rationale 3: This patient is experiencing increased bleeding. This is likely to quickly cause airway obstruction and hemorrhage, especially if a Le Fort III maxillary fracture is suspected.

Rationale 4: Transient hearing loss is common with temporal bone fractures, as these fractures frequently affect the tympanic membrane.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-1

Question 17

Type: MCSA

The nurse is assessing a patient who has received trauma to the face. It is suspected that damage to the facial nerve (CN VIII) has occurred. The nurse would prepare this patient for which intervention?

1. Surgery

2. Intubation

3. Placement of ice packs to the face for 24 hours

4. Consultation with the patients dentist

Correct Answer: 1

Rationale 1: If the facial nerve is lacerated or impacted, the patient must undergo surgical facial nerve decompression.

Rationale 2: There is no indication that the patient requires intubation for this injury.

Rationale 3: Ice packs are not the biggest priority for this patient.

Rationale 4: Consulting the patients dentist is not the priority at this time.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-1

Question 18

Type: MCSA

The nurse assesses a patient with a temporal bone fracture and notices drainage from the right nostril. Based on this assessment, which nursing diagnosis should the nurse document as priority?

1. Risk for Pain

2. Risk for Impaired Sensory Input

3. Ineffective Airway Clearance

4. Potential for Infection

Correct Answer: 4

Rationale 1: The patient may have pain, but this is not the priority.

Rationale 2: The patient is likely to have impairment of sensory input, but this is not the priority nursing diagnosis.

Rationale 3: The patients airway may be compromised by the fluid, but there is no indication that the impairment is serious.

Rationale 4: Potential for Infection is the nursing diagnosis that should be documented in the chart, as the drainage may indicate a cerebrospinal fluid leak.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Management of Care

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 26-1

Question 19

Type: MCSA

A patient who has diabetes complains of a tingling sensation in the face and is running a fever. Two hours later, the nurse notes dark drainage coming from the patients nose. Which is the nurses priority action?

1. Encourage the patient to frequently blow the nose.

2. Notify the health care provider immediately.

3. Administer antipyretics.

4. Obtain a blood glucose level.

Correct Answer: 2

Rationale 1: Frequent nose blowing is not indicated.

Rationale 2: When a diabetic patient complains of a tingling sensation and has an elevated temperature, the nurse must notify the provider of these signs of mucormycosis. The provider will treat the disorder with antifungal therapy and surgical removal of the affected tissue.

Rationale 3: Administering antipyretics is a comfort measure for the patient but is not the priority.

Rationale 4: Obtaining a blood glucose level is not indicated.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 20

Type: MCSA

A patient asks the nurse why the health care provider wants to have a follow-up appointment 6 months after a polypectomy. Which is the most appropriate response?

1. The insurance company requires the health care provider to recheck our patients.

2. Cancerous polyps are likely to recur, so we need to recheck you for this.

3. The health care provider always rechecks patients after surgical removal of polyps.

4. Polyps can recur, so the health care provider wants to make sure they havent returned.

Correct Answer: 4

Rationale 1: This is not the rationale for a recheck of the patients health.

Rationale 2: There is no indication that the polyps were malignant. They may recur, but this also does not indicate malignancy.

Rationale 3: The fact that the health care provider always does something is not a sufficient explanation to the patient.

Rationale 4: Polyps can grow back, and if they do so in a few months, the patient may require further testing to determine the exact cause.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 21

Type: MCSA

The nurse is teaching the parent of a child with allergic rhinitis about the disorder. Which statement indicates the parent understands the information?

1. The only way to avoid these symptoms is to completely avoid the trigger.

2. Since this has occurred only once, I can be sure it will not be a common problem for my child.

3. It may not always be necessary for my child to take allergy medications to avoid these symptoms.

4. Because my child has so many different triggers, antihistamines will not be effective in controlling symptoms.

Correct Answer: 3

Rationale 1: It may be impossible to completely avoid all the allergens that produce the sensitivity.

Rationale 2: There is no way to be certain the symptoms will not recur just because it is the first episode.

Rationale 3: It is possible for patients to outgrow allergies as the immune system becomes less sensitive to the trigger.

Rationale 4: There is no indication that allergy to several substances makes antihistamines ineffective.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26-2

Question 22

Type: MCSA

It is most important for the nurse to include which instruction when educating a patient who has had laryngeal papillomas removed?

1. If you experience recurrent hoarseness, come in for a check-up.

2. You should come in if you have worsening respiratory distress so we can intubate you quickly.

3. Next time we can remove them in the office, so no admission is necessary.

4. Papillomas rarely cause airway obstruction.

Correct Answer: 1

Rationale 1: Because laryngeal papillomas can recur, it is important for the patient to return if hoarseness occurs.

Rationale 2: Intubation should be avoided to reduce the likelihood of papillomas spreading to the trachea and lungs.

Rationale 3: Anytime a procedure must be performed in close proximity to the airway, admission and observation should be a priority.

Rationale 4: Papillomas can cause airway obstruction.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 23

Type: MCSA

The nurse is discussing common childhood illnesses with staff members of a day care center. The nurse determines that learning has taken place when a staff member makes which statement?

1. Pharyngitis is not usually caused by bacteria, so I do not have to be concerned with getting it.

2. Because the provider may not know for sure if the pharyngitis is caused by Streptococcus, antibiotics should be prescribed.

3. Even though the child may have a fever and a sore throat, antibiotics may not be necessary.

4. If a child has influenza, antibiotics are necessary to prevent pharyngitis.

Correct Answer: 3

Rationale 1: Pharyngitis should be considered contagious, as it is often the direct result of an upper respiratory infection such as a cold or influenza.

Rationale 2: Antibiotics should not be prescribed unless it is known that the pharyngitis is caused by bacteria.

Rationale 3: Antibiotics are necessary for pharyngitis only if it is caused by bacteria such as Streptococcus.

Rationale 4: Influenza is viral and is not affected by antibiotics. There is no certainty that influenza will lead to bacterial pharyngitis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26-3

Question 24

Type: MCMA

The nurse is planning care for a patient who has just had a permanent tracheostomy following total laryngectomy. What should the nurse consider when planning this care?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient will require isolation until the site is healed.

2. The patient will require enteral feedings until healed.

3. Writing will be an important form of communication immediately postoperatively.

4. The patient will be unable to speak normally

5. The family will be unable to communicate with the patient.

Correct Answer: 2,3,4

Rationale 1: There is no reason for isolation until the site is healed, but meticulous wound care is paramount.

Rationale 2: The patient will not be able to eat orally until the internal incision lines heal, which should take 5 to 7 days.

Rationale 3: Use of an alternative form of communication such as writing will be necessary immediately after surgery. Pantomime and lip reading can also be used, but they are not generally as efficient as writing.

Rationale 4: The patient will be unable to speak normally after the laryngectomy. It will take time to learn an alternate form of speech.

Rationale 5: Alternate forms of communication can allow the family to communicate with the patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-6

Question 25

Type: MCSA

When preparing for a maxillary resection, the nurse should provide the patient and family with which instruction?

1. It will be at least 3 to 4 days after surgery before you will be allowed out of bed.

2. It is important to keep objects within reach and in the same place at all times.

3. You will be given pain medication whenever you need it, so pain should not be a concern.

4. Your speech will not be affected, so communication will not be a problem.

Correct Answer: 2

Rationale 1: The patient will likely be mobile on day 1 postoperatively to decrease joint pain from the long surgery, decrease the likelihood of ulcer formation, and decrease the likelihood of deep vein thrombosis.

Rationale 2: Maxillary resection will likely result in some changes in eyesight, which, depending on the tumor location, could include blindness. Therefore, it is imperative that objects be kept within reach and in the same place.

Rationale 3: The patients pain will be treated, but it is inaccurate to say that the patient will be given pain medication anytime it is requested.

Rationale 4: Speech will likely be affected.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-6

Question 26

Type: MCSA

When planning care for a patient with a partial airway obstruction, which nursing intervention has the greatest priority?

1. Keeping the patient calm and relaxed

2. Providing pain medication around the clock

3. Ensuring the resuscitation team is on standby

4. Ensuring advanced airway equipment is at the bedside

Correct Answer: 4

Rationale 1: Keeping the patient calm is important, but this is not the priority intervention.

Rationale 2: Providing pain medication as necessary is important but is not the primary intervention.

Rationale 3: Having trained personnel nearby is essential but is not the primary intervention.

Rationale 4: Whenever there is the potential for rapid airway obstruction, advanced airway tools such as intubation equipment and tracheotomy supplies should always remain at the bedside. The resuscitation team will need this equipment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 26-1

Question 27

Type: MCSA

When a patients airway becomes completely obstructed, which sign will the nurse see first?

1. Pallor changing to cyanosis

2. A sudden change in mentation

3. A decrease in urine output

4. Cyanosis changing to pallor

Correct Answer: 2

Rationale 1: Changes of color are not an immediate sign of airway obstruction.

Rationale 2: A change in mentation reflects a decrease in oxygenation of the brain. This change will happen rapidly.

Rationale 3: A decrease in urine output is not an early sign of airway obstruction.

Rationale 4: Changes of color are not the most immediate sign of airway obstruction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-5

Question 28

Type: MCSA

When providing discharge instructions for the family and patient with a tracheostomy, which statement indicates the caregiver understands the instructions?

1. He cannot resume normal activities as long as he has the tracheostomy in place.

2. I will clean the site under the tracheostomy plate with half-strength hydrogen peroxide at least twice daily.

3. I can suction the trachea as often as necessary to decrease secretions coming from the tube.

4. When he is ready for decannulation, I will bring him back in to have the stoma sutured closed.

Correct Answer: 2

Rationale 1: The goal for patients discharged with a tracheostomy is to resume activities as normally as possible.

Rationale 2: Cleaning the site around the tube and under the plate will help keep secretions from irritating the skin in and around the stoma.

Rationale 3: Suctioning the trachea should be done only when absolutely necessary to prevent tracheal irritation and mucosal breakdown.

Rationale 4: The stoma is allowed to close naturally when the patient is ready for decannulation; it is never sutured closed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 26-6

Question 29

Type: MCSA

Which individual is most at risk for head and neck cancer?

1. A young female infected with human papillomavirus

2. A male with a 15-year history of smoking and alcohol use

3. A young male who has used smokeless tobacco for 2 years

4. An older male with a history of preferring meat and potatoes

Correct Answer: 2

Rationale 1: Infection with HPV increases the risk for head and neck cancer, but not as much as another factor.

Rationale 2: Using tobacco products and alcohol together is a very high-risk factor for head and neck cancer.

Rationale 3: Use of smokeless tobacco increases the risk for head and neck cancer, but not as much as another factor.

Rationale 4: A low intake of fruits and vegetables increases the risk for head and neck cancer, but not as much as another factor.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-6

Question 30

Type: MCMA

An 81-year-old woman who lives alone is in the clinic for an annual physical. She reports that she has noticed that her sense of smell is not as acute as it used to be. Which nursing interventions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ask the patient if her kitchen stove is gas or electric.

2. Remind the patient of the need to change batteries in her smoke detectors twice a year.

3. Suggest that the patient use fewer spices when cooking.

4. Recommend that the patient limit the amount she drives her car.

5. Ask the patient if she has a cat or dog living in her house.

Correct Answer: 1,2

Rationale 1: An impaired sense of smell may be a danger if the patient has gas appliances.

Rationale 2: Because this patients sense of smell is impaired, it is crucial that she have working smoke detectors in her home.

Rationale 3: The senses of smell and taste are closely associated. Increasing spices in food may make them taste better to the patient.

Rationale 4: There is no association between an impaired sense of smell and driving skills.

Rationale 5: There is no association between an impaired sense of smell and having a pet in the home.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-4

Question 31

Type: MCMA

During medication instruction about a cough syrup, the nurse says, This medicine has a really bad taste. The patient replies that she cant taste anything anyway. Which nursing assessment questions are indicated?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. How long ago did you first notice your sense of taste has diminished?

2. Did you first notice this when you developed the cold you have now?

3. Have you noticed that you are having difficulty with your sense of smell as well?

4. Have you noticed any weight gain or puffiness around your eyes?

5. How many fluids are you drinking on an average day?

Correct Answer: 1,2,3

Rationale 1: The onset of this symptom may be associated with a number of physical problems. The nurse should assess its onset.

Rationale 2: Nasal stuffiness from a cold can cause diminished sense of smell, which adversely affects the sense of taste.

Rationale 3: The sense of smell and sense of taste are closely associated. An impaired ability to smell adversely affects the sense of taste.

Rationale 4: Weight gain or puffiness around the eyes are not associated with the sense of taste.

Rationale 5: Fluid intake is not closely associated with the sense of taste.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 26-4

Question 32

Type: MCMA

A patient with an upper respiratory infection is prescribed ciprofloxacin (Cipro). Which teaching should the nurse provide about this medication?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid exposure to sunlight while you are taking this medication.

2. If you notice pain in your joints or tendons, call the office immediately.

3. You should restrict caffeine intake while taking ciprofloxacin.

4. If you develop stomach pain, immediately discontinue the medicine and call the office.

5. If you develop difficulty swallowing, please call the office.

Correct Answer: 2,3

Rationale 1: There is no indication that it is important to avoid exposure to sunlight while taking ciprofloxacin. This is important information for people taking tetracycline.

Rationale 2: Ciprofloxacin can cause tendon inflammation. If this occurs, the drug should be stopped immediately.

Rationale 3: Administration of ciprofloxacin with caffeine can cause central nervous system stimulation.

Rationale 4: There is no serious complication involving stomach pain that is associated with taking ciprofloxacin.

Rationale 5: Difficulty swallowing is not an expected adverse effect of ciprofloxacin.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-3

Question 33

Type: FIB

A patient is being treated for laryngopharyngeal reflux disease. As part of behavioral modification treatment for this disorder, the nurse advises the patient not to eat for at least ______ hours before bedtime.

Standard Text:

Correct Answer: 3

Rationale : Laryngopharyngeal reflux is retrograde reflux of gastric acid into the larynx. Avoiding the supine position for 3 hours after eating will help reduce this reflux.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-5

Question 34

Type: FIB

The nurse, suctioning a patients tracheostomy, plans for each suctioning attempt to last no longer than _____ seconds.

Standard Text:

Correct Answer: 15

Rationale : Suctioning removes oxygen as well as secretions. The suction attempt should not last over 15 seconds to decrease the possibility of hypoxia.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-6

Question 35

Type: MCMA

A patient has had myocutaneous flap reconstruction for the defect caused by a neck tumor resection. What nursing interventions are indicated for care of this flap?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Keep the patient in the supine position for at least 24 hours after surgery.

2. Regularly assess the flap for capillary refill.

3. Use tracheostomy ties to help keep the flap in place.

4. Keep the patients head turned slightly toward the operative side.

5. Keep the patient on strict bed rest until flap healing is established.

Correct Answer: 2,4

Rationale 1: The head of the bed should be elevated to at least 30 degrees to facilitate drainage of fluid and to prevent edema.

Rationale 2: The capillary refill should be brisk and less than or equal to 2 seconds.

Rationale 3: Tracheostomy ties should be positioned away from the graft to prevent pressure on the area.

Rationale 4: Positioning the patients head toward the operative side will help prevent tension on the flap.

Rationale 5: There is no reason the patient must be on bed rest while the flap heals.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 26-6

 

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