Chapter 31Upper Airway Dysfunction: Nursing Management My Nursing Test Banks

Chapter 31Upper Airway Dysfunction: Nursing Management

MULTIPLE CHOICE

1.A child is diagnosed with severe allergic rhinitis. Which of the following manifestations would the nurse most likely assess in this client?

1.

Edematous neck glands

2.

Reduced hearing

3.

Pruritis

4.

Frequent wiping of the nose with the palm of the hand

ANS: 4

Frequent wiping of the nose with the palm of the hand is one symptom seen in the client diagnosed with severe allergic rhinitis. Edematous neck glands, reduced hearing, and pruritis are not manifestations of severe allergic rhinitis.

PTS:1DIF:Analyze

REF:Allergic Rhinitis: Assessment with Clinical Manifestations

2.A client tells the nurse that she experiences a stuffy nose, nasal pain, and postnasal drip every time she works in her companys office. Which of the following types of allergic rhinitis is this client most likely experiencing?

1.

Infectious

2.

Perennial

3.

Occupational

4.

Seasonal

ANS: 3

Occupational allergic rhinitis occurs from airborne substances in the workplace. Seasonal allergic rhinitis occurs during a specific time of the year. Perennial allergic rhinitis occurs in response to exposure to environmental allergens that can occur throughout the year.  Infectious rhinitis is a nonallergic type of rhinitis.

PTS: 1 DIF: Analyze REF: Table 31-1 Types of Allergic Rhinitis

3.A client asks the nurse if there is an antihistamine that does not cause drowsiness. Which of the following medications would this client most likely prefer to treat allergic rhinitis?

1.

Diphenhydramine

2.

Chlorpheniramine maleate

3.

Clemastine

4.

Fexofenadine

ANS: 4

Fexofenadine (Allegra) is a second-generation antihistamine, and second-generation antihistamines exhibit less sedation than first-generation medications such as diphenhydramine, chlorpheniramine maleate, and clemastine.

PTS:1DIF:Apply

REF: Table 31-3 Medications Used in Treatment of Rhinitis

4.A client diagnosed with hypertension is experiencing allergic rhinitis. The nurse realizes that the medication that would not be indicated for this client would be:

1.

loratadine.

2.

montelukast.

3.

pseudoephedrine.

4.

zafirlukast.

ANS: 3

Pseudoephedrine can be contraindicated for the patient with hypertension. Loratadine, montelukast, and zafirlukast should be used cautiously for patients with hepatic impairment.

PTS:1DIF:Analyze

REF: Table 31-3 Medications Used in Treatment of Rhinitis

5.A 16-year-old client is being prescribed a medication to treat acute sinusitis. The nurse realizes that this client should not be prescribed:

1.

amoxicillin.

2.

cefuroxime.

3.

ciprofloxacin.

4.

erythromycin.

ANS: 3

Quinolones such as ciprofloxacin (Cipro) and levofloxacin (Levaquin) are contraindicated in children younger than 17 years of age.

PTS: 1 DIF: Analyze REF: Acute Sinusitis: Pharmacology

6.The nurse is caring for a client diagnosed with acute sinusitis. Which of the following symptoms is the client most likely experiencing?

1.

Anosmia

2.

Fever

3.

Halitosis

4.

Metallic taste

ANS: 1

Clients often complain of unilateral face pain, purulent nasal discharge, pain during mastication, anosmia (absence of smell), and headache. Less common symptoms include fever, nasal congestion, halitosis, toothache, metallic taste, and cough.

PTS:1DIF:Apply

REF:Acute Sinusitis: Assessment with Clinical Manifestations

7.The nurse is planning care for the client diagnosed with viral rhinitis. Which of the following would be the best goal of care for this client?

1.

Prevent secondary bacterial infection.

2.

Prevent rhinitis medicamentosa.

3.

Refrain from use of analgesics.

4.

Encourage complete participation in activities.

ANS: 1

Treatment of acute rhinitis, or the common cold, is aimed at decreasing the impact of the symptoms and preventing secondary bacterial infection. Rhinitis medicamentosa occurs from misuse of nasal decongestants. Acetaminophen or a nonsteroidal anti-inflammatory agent is useful for fever, aches, and pain. Rest is encouraged.

PTS: 1 DIF: Apply REF: Viral Rhinitis: Planning and Implementation

8.The nurse is instructing the mother of a client recovering from a tonsillectomy. Which of the following should the nurse instruct the mother to report?

1.

Difficulty swallowing

2.

Difficulty talking

3.

Excessive swallowing

4.

Pain

ANS: 3

Excessive swallowing is a sign of bleeding and should be reported. Pain and difficulty talking and swallowing are expected.

PTS:1DIF:Apply

REF:Tonsillitis and Adenoiditis: Planning and Implementation

9.Which of the following should the nurse instruct a client recovering from a tonsillectomy?

1.

Drink milk to promote healing.

2.

Gargle with salt water.

3.

Maintain good hydration.

4.

Use a straw to drink.

ANS: 3

Drinking milk does not promote healing and may encourage production of mucus. Gargling and drinking with a straw may disrupt the clot at the operative site and cause bleeding. Maintaining good hydration and eating soft foods are encouraged.

PTS:1DIF:Apply

REF:Tonsillitis and Adenoiditis: Planning and Implementation

10.A client is experiencing epistaxis. Which of the following interventions would the nurse complete?

1.

Call the doctor.

2.

Check laboratory test results.

3.

Obtain an emesis basin.

4.

Show the patient how to pinch the nose.

ANS: 4

The initial intervention for a client with epistaxis is to show the client how to lean forward and pinch the nose against the nasal septum for about 5 to 10 minutes continuously. The other interventions are not necessary at this time.

PTS: 1 DIF: Apply REF: Epistaxis: Planning and Implementation

11.A client has been diagnosed with stage IV cancer of the larynx. The nurse realizes that which of the following surgeries is recommended for this type of cancer?

1.

Hemilaryngectomy

2.

Partial laryngectomy

3.

Supraglottic laryngectomy

4.

Total laryngectomy

ANS: 4

In clients diagnosed with invasive or infiltrating tumors such as those of stage III or stage IV, the entire larynx is removed. The other surgeries only remove portions of the larynx and would be appropriate for lesser stages of the disease.

PTS: 1 DIF: Analyze REF: Laryngeal Obstruction: Surgery

12.A client is recovering from a total laryngectomy with the placement of a tracheostomy. The nurse should include which of the following instructions to this client?

1.

Clean the tracheostomy tube with soap and water daily.

2.

Limit protein in the diet.

3.

Restrict fluids.

4.

The nasogastric tube will be in for 2 weeks.

ANS: 4

Clients recovering from a laryngectomy are unable to take nutrition orally for about 10 to 14 days. During this time the client will receive nutrition via intravenous fluids, enteral feedings through a nasogastric tube, or parenteral nutrition. Protein and fluids are not limited. The tracheostomy tube is not cleaned with soap and water.

PTS: 1 DIF: Apply REF: Laryngeal Obstruction: Nutrition

13.A client diagnosed with viral rhinitis tells the nurse that she has been using a decongestant nasal spray for several weeks and the symptoms are getting worse. Which of the following does the nurse suspect is occurring with this client?

1.

Developing pneumonia

2.

Subacute rhinitis

3.

Rhinitis medicamentosa

4.

Chronic otitis media

ANS: 3

Rhinitis medicamentosa can occur with overuse of decongestant nasal sprays, and it leads to rebound nasal congestion that is often worse that the original nasal congestion. The use of nasal sprays does not cause pneumonia, subacute rhinitis, or chronic otitis media.

PTS: 1 DIF: Analyze REF: Viral Rhinitis: Planning and Implementation

MULTIPLE RESPONSE

1.The nurse is teaching a client how to use a nasal spray. Which of the following should be included in these instructions? (Select all that apply.)

1.

Blow the nose before instilling the spray.

2.

Tilt the head back and angle the tip of the bottle to the side of the nostril.

3.

Use a finger to occlude the nostril that is not receiving the spray.

4.

Inhale gently and evenly while discharging the spray into the nostril.

5.

If a second spray is recommended, immediately repeat the procedure.

6.

Blow the nose after administration of the spray.

ANS: 1, 3, 4

For the steps to be correct, the head should be slightly forward, the second spray should be given 15 to 20 seconds after the spray, and the client should not blow the nose after the administration of the spray. The client should be instructed to blow the nose before instilling the spray, to use a finger to occlude the nostril that is not receiving the spray, and to gently inhale while the spray is being delivered into the nostril.

PTS: 1 DIF: Apply REF: Patient Playbook: Installation of Nasal Spray

2.A client has been diagnosed with allergic rhinitis. Which of the following should the nurse instruct the client regarding strategies to avoid this disorder? (Select all that apply.)

1.

Remove home carpeting

2.

Reduce the use of an air conditioner

3.

Remove pets from the home

4.

Open windows in the spring and summer

5.

Use feather pillows

6.

Wash bed linens in cold water

ANS: 1, 3

Strategies to reduce the symptoms of allergic rhinitis include removing home carpeting and removing pets from the home. The client should be instructed to use an air conditioner, keep windows closed during allergy season, avoid feather pillows, and wash bed linens in hot water.

PTS: 1 DIF: Apply REF: Nursing Strategy: Allergy Avoidance Measures

3.A client is demonstrating signs of chronic sinusitis. Which of the following will the nurse most likely assess in this client? (Select all that apply.)

1.

Facial pain

2.

Fever

3.

Headache

4.

Toothache

5.

Fatigue

6.

Swollen neck glands

ANS: 1, 3, 4, 5

Manifestations of chronic sinusitis include facial pain, headache, toothache, and fatigue. Fever and swollen neck glands would indicate the disorder has spread beyond the sinuses.

PTS:1DIF:Apply

REF:Chronic Sinusitis: Assessment with Clinical Manifestations

4.With which of the following can the nurse instruct a client who is experiencing pain from a sore throat? (Select all that apply.)

1.

Gargle with warm salt water.

2.

Eat salty foods.

3.

Suck on hard candy.

4.

Drink fluids.

5.

Avoid citrus fruits.

6.

Suck on popsicles.

ANS: 1, 3, 4, 6

Interventions to reduce the pain from a sore throat include gargling with warm salt water, sucking on throat lozenges or hard candy, sucking on flavored frozen desserts or popsicles, using a humidifier in the bedroom, and drinking fluids. The client should not be instructed to eat salty foods or avoid citrus fruits.

PTS: 1 DIF: Apply REF: Patient Playbook: Easing Sore Throat Pain

5.A client is demonstrating signs of peritonsillar abscess. Which of the following will the nurse most likely assess in this client? (Select all that apply.)

1.

Bradypnea

2.

Drop in blood pressure

3.

Hot potato voice

4.

Trismus

5.

Dysphagia

6.

Sore throat

ANS: 3, 4, 5, 6

Assessment findings consistent with peritonsillar abscess include: hot potato voice; trismus, or difficulty fully opening the mouth; dysphagia, or painful swallowing; and sore throat. Bradypnea and drop in blood pressure are not assessment findings consistent with peritonsillar abscess.

PTS:1DIF:Apply

REFeritonsillar Abscess: Assessment with Clinical Manifestations

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