BN Ch. 86 Respiratory Disorders

Question 1

Collapse of a lung due to obstruction by mucus or a foreign object is called __________.

Answer 1

atelectasis

Question 2

The incentive __________ helps the client to perform respiratory exercises and to maintain lung function.

Answer 2

spirometer

Question 3

An inflammation of the double membrane covering of the lungs is called _________.

Answer 3

pleurisy

Question 4

_________ tuberculosis is a form of tuberculosis that is characterized by widespread dissemination into the body.

Answer 4

Miliary

Question 5

Profuse sweating at night is called nocturnal __________.

Answer 5

diaphoresis

Question 6

Noninvasive nuclear procedure used to diagnosed disorders in the lungs and bronchi

Answer 6

Magnetic resonance imaging

Question 7

Helps to observe lung tissue or to remove mucous plugs or foreign objects

Answer 7

Bronchoscopy

Question 8

Helps to determine which medication is most effective against an infecting organism

Answer 8

Throat culture

Question 9

Illustrates different views through which lesions, pneumonia, and other disorders can be located.

Answer 9

Lung perfusion Scan

Question 10

Write the correct sequence for the steps used in preparing for suction of a client to remove excess secretions and mucus from the airway.

1. Open the sterile suction package.
2. Place the conscious client in a semi-Fowler position.
3. Moisten the catheter with sterile saline.
4. Pick up the sterile catheter and connect it to the suction tubing.

Answer 10

2. Place the conscious client in a semi-Fowler position.
3. Open the sterile suction package.
4. Pick up the sterile catheter and connect it to the suction tubing.
5. Moisten the catheter with sterile saline.

Question 11

What are the preventive measures against tuberculosis?

Answer 11

Preventive measures against tuberculosis include the following:

• Educating the public about good general health practices.
• Burning all used tissues containing sputum or other infectious waste.
• Following community guidelines for the disposal of biohazardous waste.
• Starting early treatment to stop further spread of the disease.
• Regular follow-up with all persons who have had active tuberculosis.
• Screening of members of high-risk groups, such as immigrants and medically underserved low- income populations.
• Conducting the PPD tuberculin test in long-term residents of nursing homes, mental institutions, and correctional facilities.
• Conducting yearly screening of healthcare workers.

Question 12

What are the signs and symptoms of influenza?

Answer 12

• The major symptoms of influenza are sudden illness with muscle pain, fever, headache, sensitivity to light, burning eyes, and chills.
• Sneezing, coughing, nasal discharge, sore throat, and vomiting are also found in affected clients.
• Fever ranging from 100°F to 103°F lasts for 2 to 3 days. Other symptoms, especially cough, may persist for several weeks after the person has had the flu.

Question 13

What are the major causes of epistaxis?

Answer 13

• Irritation or injury to a small mass of capillaries on the nasal septum can cause epistaxis or nosebleed.
• Hypertension is another major cause of epistaxis, in which the bleeding is more likely to be severe.
• Certain blood disorders, cancer, and rheumatic fever are other possible causes.

Question 14

What are common structural disorders of the nose?

Answer 14

• Structural disorders of the nose include deviated septum and nasal polyps.
• A deviation in the nasal septum is a structural disorder of the nose.
• This can cause blockage in the air passage of one or both of the nostrils.
• If left uncorrected, the deformity can cause sinusitis.
• Nasal polyps are tumors found in the nose.
• Nasal polyps can obstruct breathing and sinus drainage.

Question 15

What are the symptoms of chronic sinusitis?

Answer 15

• The major symptoms of chronic sinusitis are cough due to postnasal drip, chronic headaches in the affected area, facial pain, nasal stuffiness, and fatigue.

Question 16

A nurse is assessing a client with respiratory difficulties.

a. Which data would the nurse collect from a client with respiratory disorders?

Answer 16

The nurse should collect the following data from the client:

• Observe and document respiratory rate, depth, and character.
• Determine respiratory status.
• Observe for signs of respiratory distress, dyspnea, or poor oxygenation.
• Be alert for signs or symptoms of hypoxia.
• Note any symptoms such as cough, hemoptysis, and cyanosis.
• Listen to lung sounds and breath sounds.
• Check results of skin tests related to tuberculosis or other lung conditions.
• Observe mouth and throat through visualization and palpation.

Question 17

What are the nursing diagnoses that can be established based on the data collection?

Answer 17

Based on data collection, the following nursing diagnoses can be established for clients with respiratory disorders:

• Excess fluid volume related to compromised respiratory mechanism.
• Impaired gas exchange related to lung disorders, obstruction, trauma, or altered oxygen supply.
• Ineffective airway clearance related to obstruction, trauma, painful cough, excess secretions, stroke, infection, or spinal cord injury.
• Ineffective breathing pattern related to neurologic disorder, obstruction, trauma, or pain.
• Impaired oral mucous membrane related to mouth breathing.
• Impaired verbal communication related to tracheostomy, obstruction, trauma, physical barriers, or brain damage.
• Activity intolerance related to imbalance between oxygen supply and demand, pain, lung disorders, or emphysema.
• Anxiety related to inability to breathe.

Question 18

A nurse is caring for a client who has been admitted to the healthcare facility with
pneumonia.

Which symptoms would the nurse monitor for in the client?

Answer 18

• The nurse should monitor for severe and sharp pain in the chest, chills followed by high fever (105°F or 106°F), painful coughing, tenacious sputum, pain in breathing, rapid pulse rate, rapid respiration and difficult exhalation, and mental changes such as delirium or anxiety.

Question 19

A nurse is caring for a client who has been
admitted to the healthcare facility with
pneumonia.

How would the nurse care for the client?

Answer 19

The nurse should employ the following nursing care measures when caring for the client:

• Wash hands and wear gloves.
• Monitor the client for increasingly labored respiration.
• Maintain comfortable position of the client.
• Place a pillow lengthwise under the client’s back.
• Place a blanket around the shoulders if the client has chills.
• Keep the client’s bed clean and dry.
• Monitor the client’s vital signs at least every 4 hours.
• Help the client to control fever and discomfort.
• Maintain the intravenous site or heparin lock.
• Put side rails up, especially in older clients.
• Encourage the client to cough and expectorate secretions.
• Encourage deep breathing.
• Measure intake, output, and daily weight of the client.
• Give small amounts of fluids frequently to promote hydration.
• Provide frequent mouth care and put water-soluble lubricant on the client’s lips.
• Provide a calm and quiet environment for the client.