Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems

Chapter 29: Care of Patients with Noninfectious Upper Respiratory Problems

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE

1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first?
   1. Facial pain
   2. Vital signs
   3. Bone displacement
   4. Airway patency

ANS:   D

A patent airway is the priority. The nurse first should make sure that the airway is patent and then should determine whether the client is in pain and whether bone displacement or blood loss has occurred.

DIF:     Applying/Application                         REF: 531

KEY:   Trauma| medical emergencies

MSC:   Integrated Process: Nursing Process: Implementation           NOT: 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. Which action should the nurse take next?
   1. Collect the nasal drainage on a piece of filter paper.
   2. Encourage the client to blow his or her nose.
   3. Perform a test focused on a neurologic examination.
   4. Palpate the nose, face, and neck.

ANS:   A

The client with nasal drainage after facial trauma could have a skull fracture that has resulted 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. The other actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak would increase the client’s risk for infection.

DIF:     Applying/Application                         REF: 532

KEY:   Trauma| medical emergencies

MSC:   Integrated Process: Nursing Process: Implementation           NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

3. A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first?
   1. Contact the provider for a prescription for sleep medication.
   2. Tell the client not to drink beverages with caffeine before bed.
   3. Educate the client to sleep upright in a reclining chair.
   4. Ask the client if he or she has ever been evaluated for sleep apnea.

ANS:   D

Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

DIF:            Applying/Application                         REF:    535

KEY:          Respiratory distress/failure

MSC:          Integrated Process: Nursing Process: Assessment                 NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation

4. A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?
   1. Tilt the head back as far as possible when swallowing.
   2. Tuck the chin down when swallowing.
   3. Breathe slowly and deeply while swallowing.
   4. Keep the head very still and straight while swallowing.

ANS:           B

The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

DIF:            Applying/Application                         REF:    535                   KEY: Aspiration precaution                      MSC:                                                  Integrated Process: Teaching/Learning NOT:                     Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea?
   1. A 26-year-old woman who is 8 months pregnant
   2. A 42-year-old man with gastroesophageal reflux disease
   3. A 55-year-old woman who is 50 pounds overweight
   4. 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.

DIF:            Applying/Application                         REF:    535

KEY:          Respiratory distress/failure

MSC:   Integrated Process: Nursing Process: Assessment      NOT: Client Needs Category: Health Promotion and Maintenance