Chapter 18 - Upper Respiratory Tract Disorders

Question 1

The nurse is providing client teaching to a young parent who has brought their 3-month-old infant to the clinic for a well-baby checkup. Which recommendation will the nurse make to the client to prevent the transmission of organisms to the infant during the cold season?
A. Wash hands frequently.
B. Gargle with warm salt water regularly.
C. Dress self and infant warmly.
D. Take preventative antibiotics as prescribed.

Answer 1

A. Wash hands frequently.
Rationale: Handwashing remains the most effective preventive measure to reduce the transmission of organisms. Taking prescribed antibiotics, using warm salt-water gargles, and dressing warmly do not suppress transmission. In addition, antibiotics are not prescribed for a cold.

Question 2

A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform which action?
A. Apply a cold pack to the affected area.
B. Apply heat to the forehead.
C. Perform postural drainage.
D. Increase fluid intake.

Answer 2

D. Increase fluid intake.
Rationale: For a client diagnosed with acute sinusitis, the nurse should instruct the client that increasing fluid intake and elevating the head of the bed can promote drainage. Applying a cold pack to the affected area and applying heat to the forehead will not promote sinus drainage. Postural drainage is used to remove bronchial secretions.

Question 3

The nurse is creating a plan of care for a client diagnosed with acute laryngitis. Which intervention should be included in the client’s plan of care?
A. Place warm washcloths on the client’s throat, as needed.
B. Have the client inhale warm steam three times daily.
C. Encourage the client to limit speech whenever possible.
D. Limit the client’s fluid intake to 1.5 L/day.

Answer 3

C. Encourage the client to limit speech whenever possible.
Rationale: Management of acute laryngitis includes resting the voice, avoiding irritants (including smoking), resting, and inhaling cool, not warm, steam or an aerosol. Fluid intake should be increased, not limited. Warm washcloths on the throat will not help relieve the symptoms of acute laryngitis.

Question 4

A client is being treated in the emergency department for epistaxis. Pressure has been applied to the client’s midline septum for 10 minutes, but the bleeding continues. The nurse should anticipate using which treatment to control the bleeding?
A. Irrigation with a hypertonic solution
B. Nasopharyngeal suction
C. Normal saline application
D. Silver nitrate application

Answer 4

D. Silver nitrate application
Rationale: If pressure to the midline septum does not stop the bleeding for epistaxis, additional treatment of silver nitrate application, Gelfoam, electrocautery, or vasoconstrictors may be used. Suction may be used to visualize the nasal septum, but it does not alleviate the bleeding. Irrigation with a hypertonic solution is not used to treat epistaxis. Normal saline application would not alleviate epistaxis.

Question 5

The nurse is planning the care of a client who is scheduled for a laryngectomy. The nurse should assign the highest priority to which postoperative nursing diagnosis?
A. Anxiety related to diagnosis of cancer
B. Altered nutrition related to swallowing difficulties
C. Ineffective airway clearance related to airway alterations
D. Impaired verbal communication related to removal of the larynx

Answer 5

C. Ineffective airway clearance related to airway alterations
Rationale: Each of the listed diagnoses is valid, but ineffective airway clearance is the priority nursing diagnosis for all conditions.

Question 6

Guess who loves you?

Answer 6

Me, ya girlfriend :)

Question 7

The home care nurse is assessing the home environment of a client who will be discharged from the hospital shortly after a laryngectomy. The nurse should encourage the client to use which appliance during recovery at home?
A. A room humidifier
B. An air conditioner
C. A water purifier
D. A radiant heater

Answer 7

A. A room humidifier
Rationale: The nurse stresses the importance of humidification at home and instructs the family to obtain a humidifier before the client returns home. Air conditioning may be too cool and drying for the client. A water purifier or radiant heater is not necessary.

Question 8

The nurse is caring for a client whose recent unexplained weight loss and history of smoking have prompted diagnostic testing. Which symptom is most closely associated with the early stages of laryngeal cancer?
A. Hoarseness
B. Dyspnea
C. Dysphagia
D. Frequent nosebleeds

Answer 8

A. Hoarseness
Rationale: Hoarseness is an early symptom of laryngeal cancer. Dyspnea, dysphagia, and lumps are later signs of laryngeal cancer. Nosebleeds are not associated with a diagnosis of laryngeal cancer.

Question 9

The nurse is caring for a client who needs education on medication therapy for allergic rhinitis. The client is to take cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication?
A. It inhibits the release of histamine and other chemicals.
B. It inhibits the action of proton pumps.
C. It inhibits the action of the sodium-potassium pump in the nasal epithelium.
D. It causes bronchodilation and relaxes smooth muscle in the bronchi

Answer 9

A. It inhibits the release of histamine and other chemicals
Rationale: Cromolyn inhibits the release of histamine and other chemicals. It is prescribed to treat allergic rhinitis. Beta-adrenergic agents lead to bronchodilation and stimulate beta-2 adrenergic receptors in the smooth muscle of the bronchi and bronchioles. It does not affect proton pump action or the sodium-potassium pump in the nasal cells.

Question 10

The nurse is caring for a client who presents with a severe nosebleed. The site of bleeding appears to be the anterior portion of the nasal septum. The nurse instructs the client to tilt the head forward, and the nurse applies pressure to the nose, but the client’s nose continues to bleed. Which intervention should the nurse next implement?
A. Apply ice to the bridge of the nose.
B. Lay the client down.
C. Arrange for transfer to the local emergency department.
D. Insert a cotton tampon in the affected nare.

Answer 10

D. Insert a cotton tampon in the affected nare.
Rationale: A cotton tampon may be used to try to stop the bleeding. The use of ice on the bridge of the nose has no scientific rationale for care. Laying the client down could block the client’s airway. Transfer to the emergency department is necessary only if the bleeding becomes serious

Question 11

The emergency department (ED) nurse is assessing a young gymnast who fell from a balance beam. The gymnast presents with a clear fluid leaking from the nose. Which condition should the ED nurse suspect?
A. Fracture of the cribriform plate
B. Rupture of an ethmoid sinus
C. Abrasion of the soft tissue
D. Fracture of the nasal septum

Answer 11

A. Fracture of the cribriform plate
Rationale: Clear fluid from either nostril suggests a fracture of the cribriform plate with leakage of cerebrospinal fluid. The symptoms are not indicative of an abrasion of the soft tissue or rupture of a sinus. Clear fluid leakage from the nose would not be indicative of a fracture of the nasal septum.

Question 12

A 42-year-old client is admitted to the ED after an assault. The client received blunt trauma to the face and has a suspected nasal fracture. What intervention should the nurse perform?
A. Administer nasal spray and apply an occlusive dressing to the client’s face.
B. Position the client’s head in a dependent position.
C. Irrigate the client’s nose with warm tap water.
D. Apply ice and keep the client’s head elevated.

Answer 12

D. Apply ice and keep the client’s head elevated.
Rationale: Immediately after the fracture, the nurse applies ice and encourages the client to keep the head elevated. The nurse instructs the client to apply ice packs to the nose to decrease swelling. Dependent positioning would exacerbate bleeding and the nose is not irrigated. Occlusive dressings are not used.

Question 13

The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client reports having hereditary angioedema. The nurse should identify which implication of this health condition?
A. It will result in increased loss of work days.
B. It may cause episodes of weakness due to reduced cardiac output.
C. It can cause life-threatening airway obstruction.
D. It is a risk factor for ischemic heart disease

Answer 13

C. It can cause life-threatening airway obstruction
Rationale: Hereditary angioedema is an inherited condition that is characterized by episodes of life-threatening laryngeal edema. No information supports lost days of work, reduced cardiac function, or ischemic heart disease.

Question 14

The nurse is conducting a presurgical interview for a client with laryngeal cancer. The client reports drinking approximately 20 oz (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for risk of which condition?
A. Increased risk for infection
B. Delirium tremens
C. Depression
D. Nonadherence to postoperative care

Answer 14

B. Delirium tremens
Rationale: Given the client’s reported alcohol intake and considering that alcoholism is a known risk factor for cancer of the larynx, it is essential to assess the client for risk of delirium tremens, which occurs among clients with alcohol use disorder during withdrawal from alcohol, such as would occur in the hospital following surgery. Infection is a risk in the postoperative period, but not an appropriate answer based on the client’s history. Depression and nonadherence are risks in the postoperative phase, but would not be critical short-term assessments.

Question 15

The nurse is explaining the safe and effective administration of nasal spray to a client with seasonal allergies. What information is most important to include in this teaching?
A. Finish the bottle of nasal spray to clear the infection effectively.
B. Nasal spray can only be shared between immediate family members.
C. Nasal spray should be given in a prone position.
D. Overuse of nasal spray may cause rebound congestion.

Answer 15

D. Overuse of nasal spray may cause rebound congestion
Rationale: The use of topical decongestants is controversial because of the potential for a rebound effect. The client should hold his or her head back for maximal distribution of the spray. Only the client should use the bottle.

Question 16

The nurse has been caring for a client who has been prescribed an antibiotic for pharyngitis and has been instructed to take the antibiotic for 10 days. One day 4, the client is feeling better and plans to stop taking the medication. What information should the nurse provide to this client?
A. Keep the remaining tablets for an infection at a later time.
B. Discontinue the medications if the fever is gone.
C. Dispose of the remaining medication in a biohazard receptacle.
D. Finish all the antibiotics to eliminate the organism completely.

Answer 16

D. Finish all the antibiotics to eliminate the organism completely
Rationale: The nurse informs the client about the need to take the full course of any prescribed antibiotic. Antibiotics should be taken for the entire prescribed course to eliminate the microorganisms. A client should never be instructed to keep leftover antibiotics for use at a later time. Even if the fever or other symptoms are gone, the medications should be continued. Antibiotics do not need to be disposed of in a biohazard receptacle, though they should be discarded appropriately.

Question 17

A nurse practitioner has provided care for three different clients with chronic pharyngitis over the past several months. Which client is at greatest risk for developing chronic pharyngitis?
A. A client who is a habitual user of alcohol and tobacco
B. A client who is a habitual user of caffeine and other stimulants
C. A client who eats a diet high in spicy foods
D. A client who has gastrointestinal reflux disease (GERD)

Answer 17

A. A client who is a habitual user of alcohol and tobacco
Rationale: Chronic pharyngitis is common in adults who live and work in dusty surroundings, use the voice to excess, experience chronic cough, and habitually use alcohol and tobacco. Caffeine and spicy foods have not been linked to chronic pharyngitis. GERD is not a noted risk factor

Question 18

The perioperative nurse has admitted a client who has just undergone a tonsillectomy. The nurse’s postoperative assessment should prioritize which potential complication of this surgery?
A. Difficulty ambulating
B. Hemorrhage
C. Infrequent swallowing
D. Bradycardia

Answer 18

B. Hemorrhage
Rationale: Hemorrhage is a potential complication of a tonsillectomy. Increased pulse, fever, and restlessness may indicate a postoperative hemorrhage. Difficulty ambulating and bradycardia are not common complications in a client after a tonsillectomy. Infrequent swallowing does not indicate hemorrhage; frequent swallowing does

Question 19

A 45-year-old obese man arrives in a clinic reporting daytime sleepiness, difficulty going to sleep at night, and snoring. The nurse should recognize the manifestations of which health problem?
A. Adenoiditis
B. Chronic tonsillitis
C. Obstructive sleep apnea
D. Laryngeal cancer

Answer 19

C. Obstructive sleep apnea
Rationale: Obstructive sleep apnea occurs in men, especially those who are older and overweight. Symptoms include excessive daytime sleepiness, insomnia, and snoring. Daytime sleepiness and difficulty going to sleep at night are not indications of tonsillitis or adenoiditis. This client’s symptoms are not suggestive of laryngeal cancer.

Question 20

The nurse is caring for a client with epistaxis in the emergency department. Which information should the nurse include in client discharge teaching as a way to prevent epistaxis?
A. Keep nasal passages clear.
B. Use decongestants regularly.
C. Humidify the indoor environment.
D. Use a tissue when blowing the nose.

Answer 20

C. Humidify the indoor environment
Rationale: Discharge teaching for prevention of epistaxis should include the following: avoid forceful nose blowing, straining, high altitudes, and nasal trauma (nose picking). Adequate humidification may prevent drying of the nasal passages. Keeping nasal passages clear and using a tissue when blowing the nose are not included in discharge teaching for the prevention of epistaxis. Decongestants are not indicated.

Question 21

The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?
A. Assessment of body image
B. Assessment of jugular venous pressure
C. Assessment of carotid pulse
D. Assessment of swallowing ability

Answer 21

D. Assessment of swallowing ability
Rationale: A common postoperative complication from this type of surgery is difficulty in swallowing, which creates a potential for aspiration. Cardiovascular complications are less likely at this stage of recovery. The client’s body image should be assessed, but dysphagia has the potential to affect the client’s airway, and is a consequent priority

Question 22

The nurse is performing the health interview of a client with chronic rhinosinusitis who experiences frequent nose bleeds. The nurse asks the client about the current medication regimen. Which medication would put the client at a higher risk for recurrent epistaxis?
A. Oxymetazoline nasal
B. Beclomethasone
C. Levothyroxine
D. Albuterol

Answer 22

B. Beclomethasone
Rationale: Beclomethasone should be avoided in clients with recurrent epistaxis because it is a risk factor. The other listed medications do not increase the risk for epistaxis

Question 23

The nurse is performing a nutritional assessment on a client who has been diagnosed with cancer of the larynx. Which laboratory values would be assessed when determining the nutritional status of the client? Select all that apply.
A. White blood cell count
B. Protein level
C. Albumin level
D. Platelet count
E. Glucose level

Answer 23

B. Protein level
C. Albumin level
E. Glucose level
Rationale: The nurse assesses the client’s general state of nutrition, including height and weight and body mass index, and reviews laboratory values that assist in determining the client’s nutritional status (albumin, protein, glucose, and electrolyte levels). The white blood cell count and the platelet count would not normally assist in determining the client’s nutritional status.

Question 24

The nurse is teaching a client with allergic rhinitis about the safe and effective use of medications. Which information would be the most essential to give this client about preventing possible drug interactions?
A. Prescription medications can be safely supplemented with over-the-counter (OTC) medications.
B. Use only one pharmacy so the pharmacist can check drug interactions.
C. Read drug labels carefully before taking OTC medications.
D. Consult the Internet before selecting an OTC medication

Answer 24

C. Read drug labels carefully before taking OTC medications.
Rationale: Client education is essential when assisting the client in the use of all medications. To prevent possible drug interactions, the client is cautioned to read drug labels before taking any OTC medications. Some websites are reliable and valid information sources, but this is not always the case. Clients do not necessarily need to limit themselves to one pharmacy, though checking for potential interactions is important. Not all OTC medications are safe additions to prescription medication regimens

Question 25

The nurse is caring for a client with a history of a renal transplant who has just been diagnosed with chronic rhinosinusitis. While being admitted to the clinic, the client asks, “Will this chronic infection hurt my new kidney?” What should the nurse know about chronic rhinosinusitis in this client?
A. The client will have exaggerated symptoms of rhinosinusitis due to immunosuppression.
B. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis.
C. Chronic rhinosinusitis can damage the transplanted organ.
D. Immunosuppressive drugs can cause organ rejection.

Answer 25

B. Taking immunosuppressive drugs can contribute to chronic rhinosinusitis.
Rationale: URIs, specifically chronic rhinosinusitis and recurrent acute rhinosinusitis, may be linked to primary or secondary immune deficiency or treatment with immunosuppressive therapy (i.e., for cancer or organ transplantation). Typical symptoms may be blunted or absent due to immunosuppression. No evidence indicates damage to the transplanted organ due to chronic rhinosinusitis. Immunosuppressive drugs do not cause organ rejection.

Question 26

The nurse is caring for a client with a severe nosebleed. The health care provider inserts a nasal sponge. What should the nurse teach the client about this intervention?
A. The sponge creates a risk for viral sinusitis
B. The sponge can stay in place for 3 to 4 days if needed
C. The client should remain supine while the sponge is in place
D. NSAIDs are contraindicated while the sponge is in place

Answer 26

B. The sponge can stay in place for 3 to 4 days if needed
Rationale: A compressed nasal sponge may be used. Once the sponge becomes saturated with blood or is moistened with a small amount of saline, it will expand and produce tamponade to halt the bleeding. The packing may remain in place for 48 hours or up to 3 or 4 days if necessary to control bleeding. This does not require the client to be supine or to avoid all NSAIDs. Packing does not increase the risk for sinusitis

Question 27

A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?
A. Teaching focuses on safe and effective use of antibiotics.
B. The client should be preliminarily screened for surgery.
C. Symptom management is the main focus of medical and nursing care.
D. The focus of care is resting the voice to prevent chronic hoarseness

Answer 27

C. Symptom management is the main focus of medical and nursing care.
Rationale: Nursing care for clients with viral pharyngitis focuses on symptomatic management. Antibiotics are not prescribed for viral etiologies. Surgery is not indicated in the treatment of viral pharyngitis. Chronic hoarseness is not a common sequela of viral pharyngitis, so teaching ways to prevent it would be of no use in this instance.

Question 28

The nurse is providing education to a client diagnosed with acute rhinosinusitis. For which possible complication should the nurse teach the client to seek follow-up care?
A. Periorbital edema
B. Headache unrelieved by over-the-counter medications
C. Clear drainage from nose
D. Blood-tinged mucus when blowing the nose

Answer 28

A. Periorbital edema
Rationale: Client teaching is an important aspect of nursing care for the client with acute rhinosinusitis. The nurse instructs the client about symptoms of complications that require follow-up. Referral to a health care provider is indicated if periorbital edema and severe pain on palpation occur. Clear drainage and blood-tinged mucus do not require follow-up if the client has acute rhinosinusitis. A persistent headache does not necessarily warrant follow-up.

Question 29

A client states that the client’s family has had several colds during this winter and spring despite their commitment to handwashing. The high communicability of the common cold is attributable to which factor?
A. Cold viruses are increasingly resistant to common antibiotics.
B. The virus is shed for 2 days prior to the emergence of symptoms.
C. A genetic predisposition to viral rhinitis has recently been identified.
D. Overuse of over-the-counter (OTC) cold remedies creates a “rebound” susceptibility to future colds.

Answer 29

B. The virus is shed for 2 days prior to the emergence of symptoms
Rationale: Colds are highly contagious because virus is shed for about 2 days before the symptoms appear and during the first part of the symptomatic phase. Antibiotic resistance is not relevant to viral illnesses, and OTC medications do not have a “rebound” effect. Genetic factors do not exist for viral rhinitis

Question 30

It is cold season, and the school nurse has been asked to provide an educational event for the parent teacher organization of the local elementary school. Which information should the nurse include in education about the treatment of pharyngitis?
A. Pharyngitis is more common in children whose immunizations are not up to date.
B. There are no effective, evidence-based treatments for pharyngitis.
C. Use of warm saline gargles or throat irrigations can relieve symptoms.
D. Heat may increase the spasms in pharyngeal muscles.

Answer 30

C. Use of warm saline gargles or throat irrigations can relieve symptoms
Rationale: Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. Applying heat to the throat would reduce, not increase, spasms in the pharyngeal muscles. There is no evidence that pharyngitis is more common in children whose immunizations are not up to date. Warm saline gargles and throat irrigations are evidence-based treatments for pharyngitis.

Question 31

The nurse is doing discharge teaching in the ED with a client who had a nosebleed. What should the nurse include in the discharge teaching of this client?
A. Avoid blowing the nose for the next 45 minutes.
B. In case of recurrence, apply direct pressure for 15 minutes.
C. Do not take aspirin for the next 2 weeks.
D. Seek immediate medical attention if the nosebleed recurs.

Answer 31

B. In case of recurrence, apply direct pressure for 15 minutes.
Rationale: The nurse explains how to apply direct pressure to the nose with the thumb and the index finger for 15 minutes in case of a recurrent nosebleed. If recurrent bleeding cannot be stopped, the client is instructed to seek additional medical attention. ASA is not contraindicated in most cases and the client should avoid blowing the nose for an extended period of time, not just 45 minutes

Question 32

A client has had a nasogastric tube in place for 6 days due to the development of paralytic ileus after surgery. In light of the prolonged presence of the nasogastric tube, the nurse should prioritize assessments related to which complication?
A. Sinus infections
B. Esophageal strictures
C. Pharyngitis
D. Laryngitis

Answer 32

A. Sinus infections
Rationale: Clients with nasotracheal and nasogastric tubes in place are at risk for development of sinus infections. Thus, accurate assessment of clients with these tubes is critical. Use of a nasogastric tube is not associated with the development of esophageal strictures, pharyngitis, or laryngitis.

Question 33

A mother calls the clinic asking for a prescription for amoxicillin for her 2-year-old child, who has what the nurse suspects to be viral rhinitis. What should the nurse explain to this mother?
A. “I will relay your request promptly to the doctor, but I suspect that the doctor won’t get back to you if it’s a cold.”
B. “I’ll certainly inform the doctor, but if it is a cold, antibiotics won’t be used because they do not affect the virus.”
C. “I’ll phone in the prescription for you since it can be prescribed by the pharmacist.”
D. “Amoxicillin is not likely the best antibiotic, but I’ll call in the right prescription for you.”

Answer 33

B. “I’ll certainly inform the doctor, but if it is a cold, antibiotics won’t be used because they do not affect the virus.”
Rationale: Antimicrobial agents (antibiotics) should not be used because they do not affect the virus or reduce the incidence of bacterial complications. In addition, their inappropriate use has been implicated in development of organisms resistant to therapy. It would be inappropriate to tell the client that the health care provider will not respond to the request

Question 34

The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. Which assessment should the nurse prioritize?
A. The client’s swallowing ability
B. The client’s airway patency
C. The client’s pain level
D. Signs and symptoms of infection

Answer 34

B. The client’s airway patency
Rationale: The client with a laryngectomy is at risk for airway occlusion and respiratory distress. As in all nursing situations, assessment of the airway is a priority over other potential complications and assessment parameters, including swallowing ability, pain level, and signs and symptoms of infection, all of which can be assessed after assessing the client’s airway patency

Question 35

The nurse has noted the emergence of a significant amount of fresh blood at the drain site of a client who is postoperative day 1 following total laryngectomy. What is the nurse’s best action?
A. Remove the client’s drain and apply pressure with a sterile gauze.
B. Assess the client, reposition the client supine, and apply wall suction to the drain.
C. Rapidly assess the client and notify the surgeon about the client’s bleeding.
D. Administer a STAT dose of vitamin K to aid coagulation.

Answer 35

C. Rapidly assess the client and notify the surgeon about the client’s bleeding
Rationale: The nurse promptly notifies the surgeon of any active bleeding, which can occur at a variety of sites, including the surgical site, drains, and trachea. The drain should not be removed or connected to suction. Supine positioning would exacerbate the bleeding. Vitamin K would not be given without an order

Question 36

The nurse is creating a care plan for a client who is status post-total laryngectomy. Much of the plan consists of a long-term postoperative communication plan for alaryngeal communication. Which form of alaryngeal communication is generally most preferred?
A. Esophageal speech
B. Electric larynx
C. Tracheoesophageal puncture
D. American sign language (ASL)

Answer 36

C. Tracheoesophageal puncture
Rationale: Tracheoesophageal puncture is simple and has few complications. It is associated with high phonation success, good phonation quality, and steady long-term results. As a result, it is preferred over esophageal speech, electric larynx, and ASL

Question 37

A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client’s nutrition during treatment?
A. A 1.5 L/day fluid restriction
B. A high-potassium, low-sodium diet
C. A liquid or soft diet
D. A high-protein diet

Answer 37

C. A liquid or soft diet
Rationale: A liquid or soft diet is provided during the acute stage of the disease, depending on the client’s appetite and the degree of discomfort that occurs with swallowing. The client is encouraged to drink as much fluid as possible (at least 2 to 3 L/day). There is no need for increased potassium or protein intake.

Question 38

A client has just been diagnosed with squamous cell carcinoma of the neck. While the nurse is doing health education, the client asks, “Does this kind of cancer tend to spread to other parts of the body?” What is the nurse’s best response?
A. “In many cases, this type of cancer spreads to other parts of the body.”
B. “This cancer usually does not spread to distant sites in the body.”
C. “You will have to speak to your oncologist about that.”
D. “When it spreads to other parts of the body, the care team will treat it aggressively.”

Answer 38

B. “This cancer usually does not spread to distant sites in the body.”
Rationale: The incidence of distant metastasis with squamous cell carcinoma of the head and neck (including larynx cancer) is relatively low. The client’s prognosis is determined by the oncologist, but the client has asked a general question and it would be inappropriate to refuse a response. The nurse must not downplay the client’s concerns.

Question 39

A client’s total laryngectomy has created a need for alaryngeal speech, which will be achieved through the use of tracheoesophageal puncture. What action should the nurse describe to the client when teaching about this process?
A. Training how to perform controlled belching
B. Use of an electronically enhanced artificial pharynx
C. Insertion of a specialized nasogastric tube
D. Fitting for a voice prosthesis

Answer 39

D. Fitting for a voice prosthesis
Rationale: In clients receiving tracheoesophageal puncture, a valve is placed in the tracheal stoma to divert air into the esophagus and out the mouth. Once the puncture is surgically created and has healed, a voice prosthesis is fitted over the puncture site. A nasogastric tube and belching are not required. An artificial pharynx is not used