Preview Extract
Chapter 34
1. Which client requires the most immediate intervention by the nurse?
1. A client with a maxillary fracture who has been swallowing frequently
2. A client with a temporal bone fracture experiencing hearing loss
3. A client with a fractured nasal bone experiencing a nosebleed
4. A client with a mandibular fracture who has facial numbness and tingling
Answer: A client with a maxillary fracture who has been swallowing frequently
Rationale:
The client with a maxillary fracture who is swallowing frequently is the priority, as this client
is experiencing increased bleeding. This is likely to quickly cause airway obstruction and
hemorrhage, especially if a LeFort III maxillary fracture is suspected. Transient hearing loss
is common with temporal bone fractures, as these fractures frequently affect the tympanic
membrane. The client with the fractured nasal bone will experience a nosebleed, but is not in
danger of hemorrhage as is the client with the maxillary fracture. The numbness and tingling
in the client with the mandibular fracture is not the priority, as this is expected and transient
as the edema of the trigeminal facial nerves dissipates.
2. The nurse is assessing a client who has received trauma to the face. If the client states, “My
gums feel like they do when I have a cavity filled,” which nursing action would the nurse
expect to include in the plan of care?
1. Preparing the client for surgery
2. Calling the client’s dentist
3. Preparing equipment for intubation
4. Keeping ice packs available for the next 24 hours
Answer: Preparing the client for surgery
Rationale:
Most likely, the client has a mandibular fracture causing trauma to cranial nerve V, or the
trigeminal nerve. As the trigeminal nerve supplies sensation to the teeth, the numbness
indicates a mandibular fracture, requiring surgery. Planning to call the dentist is not helpful at
present since the client requires surgery. There is no indication the client requires intubation
at this time. The client may need ice packs, but the priority for planning is surgery.
3. The nurse assesses a client with a temporal bone fracture and notices drainage from the
right nare. Based on this assessment, which nursing diagnosis should the nurse document as
priority for this client?
1. Potential for infection
2. Risk for pain
3. Risk for impaired sensory input
4. Foreign body
Answer: Potential for infection
Rationale:
Potential for infection is the nursing diagnosis that should be documented in the chart, as the
drainage may indicate a cerebrospinal fluid leak. While the client may be in pain and may
have an impaired sense of smell, the potential for infection from meningitis is the priority.
There is no indication the client has a foreign body.
4. A client in the unit who has diabetes complains of a tingling sensation in the face and has a
started running a fever. Two hours later, the nurse notes a dark nasal drainage coming from
the client’s nose. Which is the nurse’s priority action?
1. Notify the healthcare provider immediately.
2. Administer antipyretics.
3. Obtain a blood glucose level.
4. Encourage the client to frequently blow his or her nose.
Answer: Notify the healthcare provider immediately.
Rationale:
When a diabetic client complains of a tingling sensation and has an elevated temperature, the
nurse must notify the provider of these signs of mucormycosis. The provider needs to treat
with antifungal therapy and surgical removal of the affected tissue. Administering
antipyretics is a comfort measure for the client, but is not the priority. Obtaining a blood
glucose level and frequent nose blowing is not necessary, and therefore not a priority.
5. The client 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. “Polyps can return, so the health care provider wants to make sure they haven’t returned.”
2. “The health care provider always rechecks clients after surgical removal of polyps.”
3. “The insurance company requires the health care provider to recheck our clients.”
4. “Cancerous polyps are likely to recur, so we need to recheck you for this.”
Answer: “Polyps can return, so the health care provider wants to make sure they haven’t
returned.”
Rationale:
Polyps can grow back, and if they do so in a few months, the client may require further
testing to determine the exact cause. Just because they grew back does not make them more
likely to be cancerous. The other options are not addressing the reason behind the recheck for
the client’s health.
6. The nurse is discussing care of the client with rhinitis. Which of the following statements
indicates the caregiver understands the content of the teaching session?
1. “It may not always be necessary to take allergy medications to avoid these symptoms.”
2. “Since there are so many different triggers, it will be necessary to take allergy injections
forever.”
3. “The only way to avoid these symptoms is to completely avoid the trigger.”
4. “Since this has only occurred once, I can be sure it is not allergic in nature.”
Answer: “It may not always be necessary to take allergy medications to avoid these
symptoms.”
Rationale:
It is possible for clients to outgrow allergies as the immune system becomes less sensitive to
the trigger. In some clients with allergies, injections are given until the client reaches a
maintenance dose, when it is possible for the injections to be discontinued. There are ways to
avoid symptoms other than completely avoiding the trigger, including taking allergy
medications on a daily basis. There is no way to be certain the symptoms will not recur just
because it is the first episode.
7. When caring for a client after dental surgery, which nursing action is most essential?
1. Educating the client about proper oral care
2. Administering analgesics as ordered
3. Encouraging the client to floss daily
4. Administering antipyretics as ordered
Answer: Educating the client about proper oral care
Rationale:
Once a dental abscess is drained and the affected areas cleaned, the most essential nursing
action is educating the client about proper oral care. This includes both wound care after
surgery and oral care to help prevent further abscesses in the future. Analgesics and
antipyretics are important, but physical needs such as wound care take priority. Encouraging
the client to floss daily is included in education on proper oral care. There is more to proper
oral care than just daily flossing.
8. It is most important for the nurse to include which instruction in the healthcare teaching of
a client who has had laryngeal papillomas removed?
1. “If you experience recurrent hoarseness, come in for a check-up.”
2. “Papillomas rarely cause airway obstruction.”
3. “Next time, we can remove them in the office, so no admission is necessary.”
4. “You should come in if you have worsening respiratory distress, so we can intubate you
quickly.”
Answer: “If you experience recurrent hoarseness, come back in for a check-up.”
Rationale:
Since laryngeal papillomas can recur, it is important for the client to be aware and return if
hoarseness occurs. Papillomas can cause airway obstruction, but intubation should be avoided
to lessen the likelihood they spread to the trachea and lungs. Anytime a procedure must be
done involving close proximity to the airway, admission and observation should be a priority.
9. The nurse is discussing common illnesses experienced in childhood with staff members of
a daycare. Appropriate learning has taken place when which of the following statements is
made?
1. “Even though the child may have a fever and a sore throat, antibiotics may not be
necessary.”
2. “Since the provider may not know for sure if the pharyngitis is caused by streptococcus or
not, antibiotics should be prescribed.”
3. “The child diagnosed with pharyngitis cannot return to school until the antibiotics are
completed.”
4. “Since pharyngitis is not usually caused by bacteria, I do not have to be concerned with
getting it.”
Answer: “Even though the child may have a fever and a sore throat, antibiotics may not be
necessary.”
Rationale:
Antibiotics are only necessary for pharyngitis if caused by bacteria such as streptococcus.
This is known through a rapid strep test and/or a throat culture. If it is bacterial in origin, the
child can return to school when he or she has been on antibiotics for a full 24 hours.
Pharyngitis should be considered contagious, as it is the direct result of an upper respiratory
infection such as a cold or influenza.
10. A client states, “I don’t watch television because I cannot stand how the people look on
my television.” Which question should the nurse ask next?
1. “What is it about how the people look on the television that bothers you?”
2. “Do you have an older television set that needs repair?”
3. “Is the screen on your television dusty?”
4. “Can you see the writing on your prescription bottles?”
Answer: “What is it about how the people look on the television that bothers you?”
Rationale:
Asking the client what bothers him or her about the television allows the client to elaborate
on the issue without making assumptions. Open-ended questions are usually more appropriate
because they elicit more information. Asking about the television set diverts attention from
the client, and asking about the writing on the prescription bottles assumes the client cannot
see well enough to view television.
11. When planning care for a client with a permanent laryngectomy airway, the nurse should
include which considerations?
Select all that apply.
1. The client will be unable to speak.
2. The client will require enteral feedings until healed.
3. The family and client cannot read.
4. The family may be unable to communicate with the client.
5. The client requires isolation until the site is healed.
Answer: 1. The client will be unable to speak.
2. The client will require enteral feedings until healed.
3. The family and client cannot read.
Rationale:
The client will be unable to speak. Until the surgical site is healed, the client will be unable to
speak. The client will require enteral feedings until healed. The client will require enteral
feedings until healed. The family and client cannot read. Until the surgical site is healed, the
client will be unable to speak. Communication will be much more difficult when both family
and client cannot read. The family may be unable to communicate with the client. The nurse
must devise methods for family, nurse, and client to communicate before the surgery takes
place. The client requires isolation until the site is healed. There is no reason for isolation
until healed, but meticulous wound care is paramount.
12. When preparing for a maxillary resection, the nurse should provide the client and family
with which instruction?
1. “It is important to keep objects within reach and in the same place at all times.”
2. “Your speech will not be affected, so communication will not be a problem.”
3. “You will be given pain medication whenever you need it, so pain should not be a
concern.”
4. “It will be at least 3 to 4 days after surgery before you will be allowed out of bed.”
Answer: “It is important to keep objects within reach and in the same place at all times.”
Rationale:
Maxillary resection will most likely result in some changes in eyesight, and could include
blindness depending on tumor location. Therefore, it is imperative to keep objects within
reach and in the same place. Speech will most likely be affected, and clients will be
concerned about pain and may not be able to get medication whenever they request it. Clients
will most 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
thromboses.
13. When planning care for a client with a partial airway obstruction, which nursing
intervention has the greatest priority?
1. Ensuring advanced airway equipment is at the bedside
2. Ensuring the resuscitation team is on standby
3. Keeping the client calm and relaxed
4. Providing pain medication around the clock
Answer: Ensuring advanced airway equipment is at the bedside
Rationale:
Whenever a client has the potential to quickly lose the airway, advanced airway tools such as
intubation equipment and tracheotomy supplies should always remain at the bedside. The
resuscitation team, keeping the client calm, and providing pain medication are needed, but
maintaining the airway is priority.
14. When a client’s airway becomes completely obstructed, which sign will the nurse see
first?
1. A sudden inability to follow directions
2. Cyanosis changing to pallor
3. Pallor changing to cyanosis
4. A decrease in urine output
Answer: A sudden inability to follow directions
Rationale:
When the client loses the airway, he or she will have a change in the level of consciousness
that the nurse will first see as an altered mental status. This change precedes any color
changes and a decrease in urine output.
15. When providing discharge instructions for the family and client with a tracheostomy,
which of the following statements indicates the caregiver understands the instructions?
1. “I will clean the site under the tracheostomy plate with half-strength hydrogen peroxide at
least twice daily.”
2. “When he is ready for decannulation, I will bring him back in to have the stoma sutured
closed.”
3. “I can suction the trachea as often as necessary to decrease secretions coming from the
tube.”
4. “He cannot resume normal activities as long as he has the trachesostomy in place.”
Answer: “I will clean the site under the tracheostomy plate with half strength hydrogen
peroxide at least twice daily.”
Rationale:
Cleaning the site around the tube and under the plate will help keep secretions from irritating
the skin in and around the stoma. The stoma is allowed to close naturally when the client is
ready for decannulation; it is never sutured closed. Suctioning the trachea should only be
done only when absolutely necessary to prevent tracheal irritation and mucosal breakdown.
The goal for clients discharged with a tracheostomy is to resume activities as normally as
possible.
16. Which individual is most at risk for head and neck cancer?
1. An older female with a history of using “snuff”
2. An older male with a history of preferring “meat and potatoes”
3. A young male with a history of smoking for 15 years
4. A young female infected with human papillomavirus
Answer: An older female with a history of using “snuff”
Rationale:
Any client with a history of using smokeless tobacco is 50 times more likely to experience a
cancer of the cheeks, gums, and inner surface of the lips. Decreased intake of fruits and
vegetables, smoking, and human papillomavirus infection all increase the risk, but not as high
as in those using smokeless tobacco.
17. Which individual has the most risk factors for developing head and neck cancer?
1. A Chinese American who drinks one alcoholic beverage every day and has smoked half a
pack of cigarettes daily for the past 20 years
2. An African American who drinks and smokes a cigar when on the town with friends for
their monthly get-together
3. An Italian American who has had a liver transplant in the past 6 months
4. A Japanese American who has a poor diet consisting of mostly rice and meat
Answer: A Chinese American who drinks one alcoholic beverage every day and has smoked
half a pack of cigarettes daily for the past 20 years
Rationale:
The risk for cancer is correlated with the length and amount of tobacco smoked or chewed,
and rises even higher when tobacco use is combined with alcohol use. Individuals who are
from an Asian heritage also have an increased risk of nasopharyngeal cancer, especially if
they have a history of eating salt-preserved fish. The other cultural heritages have no known
link to developing head and neck cancer, and the individual’s lifestyles place them at lower
risk.
18. After a client has had a surgical resection for a head and neck cancer, which is the priority
nursing diagnosis?
1. Risk for Impaired Gas Exchange related to new tracheotomy
2. Knowledge Deficit related to necessary home care
3. Risk for Injury related to CSF leak
4. Anxiety related to changes in health status
Answer: Risk for Impaired Gas Exchange related to new tracheotomy
Rationale:
Nursing diagnoses currently applicable to the client’s hospitalization take priority over those
after discharge. Impaired Gas Exchange takes priority because it relates to a basic physical
need for a patent airway and ability to circulate oxygen to the peripheral and central
circulation. Risk for Injury is important but is secondary to airway. Anxiety is important, but
is psychosocial in nature and is therefore secondary to all physical nursing diagnoses.
19. Which most accurately describes the priority goal for wound care management in the
client who has undergone surgical resection of a head and neck cancer?
1. Prevent shifts in electrolyte and fluid balances.
2. Prevent fistula development in the wound bed.
3. Prevent decubitus ulcer formation.
4. Prevent flap failure.
Answer: Prevent shifts in electrolyte and fluid balances.
Rationale:
While all four options are important in the postoperative period, the priority is preventing
shifts in fluid and electrolytes through monitoring for bleeding, either from the carotid artery
if at or near the surgical site, and excessive drainage from surgical drains. In addition, the
nurse must observe for a chyle leak from the lymph system. Both of these can cause lifethreatening alterations in potassium, sodium, calcium, and magnesium levels, having deadly
cardiac manifestations.
20. The nurse is discussing discharge instructions with the family of a client going home after
a total laryngectomy. Which statement indicates teaching has been unsuccessful?
1. “The laryngectomy will be in place until she can breathe normally again.”
2. “I should make sure she keeps her head in a neutral position to decrease any airway
obstruction.”
3. “I should purchase a small spray bottle so she can humidify her airway when needed.”
4. “I should clean the stoma about every 8 hours to make sure it stays clean and free of
debris.”
Answer: “The laryngectomy will be in place until she can breathe normally again.”
Rationale:
The laryngectomy is the client’s only airway and is permanent. A neutral position helps keep
the laryngeal airway open, and the mist from the spray bottle will be necessary until the
airway gets used to unfiltered, unwarmed air. The stoma is cleaned at least every 8 hours to
prevent infection and irritation at the site.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
