lOMoARcPSD|3013804
Chapter 26 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the
nurse perform first?
a.
Facial pain
b.
Vital signs
c.
Bone displacement
d.
Airway patency
ANS: D
A patent airway is the priority. The nurse first would make sure that the airway is patent
and then would determine whether the client is in pain and whether bone displacement or
blood loss has occurred.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Trauma, Medical emergencies
MSC: 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. What action would the nurse take next?
a.
Collect the nasal drainage on a piece of filter paper.
b.
Encourage the client to blo w h is o r h e r no s e.
c.
Perform a test focused on aGneurologic
R A D examination.
E S L A B . COM
d.
Palpate the nose, face, and neck.
ANS: A
The client with nasal drainage after facial trauma could have a skull fracture resulting 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 and tests positive for glucose. The other
actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak
would increase the patient’s risk for infection.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse teaches a client who had a supraglottic laryngectomy. Which technique would
the nurse teach the client to prevent aspiration?
a.
Tilt the head back as far as possible when swallowing.
b.
Swallow twice while bearing down.
c.
Breathe slowly and deeply while swallowing.
d.
Keep the head very still and straight while swallowing.
ANS: B
Chapter 26 notes
Care Management (Keiser
University)
, lOMoARcPSD|3013804
Test Bank for Medical Surgical Nursing 10th Edition Ignatavicius (Test Bank PDF Files)
Chapter 26: Concepts of Care for Patients With Noninfectious Upper Respiratory
Problems
Ignatavicius: Medical-Surgical Nursing, 10th Edition
MULTIPLE CHOICE
1. A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the
nurse perform first?
a.
Facial pain
b.
Vital signs
c.
Bone displacement
d.
Airway patency
ANS: D
A patent airway is the priority. The nurse first would make sure that the airway is patent
and then would determine whether the client is in pain and whether bone displacement or
blood loss has occurred.
DIF: Applying TOP: Integrated Process: Nursing Process: Assessment
KEY: Trauma, Medical emergencies
MSC: 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. What action would the nurse take next?
a.
Collect the nasal drainage on a piece of filter paper.
b.
Encourage the client to blo w h is o r h e r no s e.
c.
Perform a test focused on aGneurologic
R A D examination.
E S L A B . COM
d.
Palpate the nose, face, and neck.
ANS: A
The client with nasal drainage after facial trauma could have a skull fracture resulting 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 and tests positive for glucose. The other
actions would be appropriate but are not as high a priority as assessing for CSF. A CSF leak
would increase the patient’s risk for infection.
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Medical emergencies
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
3. A nurse teaches a client who had a supraglottic laryngectomy. Which technique would
the nurse teach the client to prevent aspiration?
a.
Tilt the head back as far as possible when swallowing.
b.
Swallow twice while bearing down.
c.
Breathe slowly and deeply while swallowing.
d.
Keep the head very still and straight while swallowing.
ANS: B
