Question 1

A patient with nasal trauma has clear, watery fluid dripping from the nose. The nurse performs the halo test, which is positive. What does this positive result indicate?

Accepted Answer

A positive halo test in a patient with nasal trauma indicates the presence of cerebrospinal fluid (CSF), which can be a sign of a skull base fracture. It is important to notify the healthcare provider immediately and keep the patient flat to prevent further leakage of CSF.

Question 2

It is most important for the nurse to include which instruction when educating a patient who has had laryngeal papillomas removed?

Accepted Answer

Recurrent hoarseness can indicate the reappearance of laryngeal papillomas and prompt medical attention may prevent airway obstruction. Option B is not the best choice as it implies that intubation may be necessary, which is a last resort for airway management. Option C may not be applicable to all cases and is not the most important instruction for the patient. Option D is incorrect as airway obstruction is a potential complication of laryngeal papillomas.

Question 3

The nurse is teaching the parent of a child with allergic rhinitis about the disorder. Which statement indicates the parent understands the information?

Accepted Answer

Option A is incorrect because avoiding triggers completely is rarely possible. Option B is incorrect because the child has been diagnosed with allergic rhinitis, which means they will likely experience these symptoms again in the future. Option D is incorrect because antihistamines are often effective in controlling allergy symptoms. Option C is the correct option as it indicates that the parent understands that medication may not always be necessary, and suggests that the parent is aware of potential non-pharmacological interventions.

Question 4

The nurse assesses a patient with a temporal bone fracture and notices drainage from the right nostril. Based on this assessment, which nursing diagnosis should the nurse document as priority?

Accepted Answer

The drainage from the nostril could indicate cerebrospinal fluid leakage, which increases the risk of infection, such as meningitis. Therefore, addressing the potential for infection is the priority.

Question 5

While eating a meal in the hospital, a patient demonstrates difficulty breathing and signs of choking. The nurse realizes that the patient is experiencing which condition?

Accepted Answer

Difficulty breathing and signs of choking while eating are indicative of a potential laryngeal obstruction.

Question 6

A patient who is scheduled for a partial laryngectomy asks if he will still be able to talk after the surgery. What are appropriate nursing responses to this patient?. Select all that apply.

Accepted Answer

It is important for the nurse to provide accurate information to the patient while also acknowledging that every patient's case is different. Therefore, options A and D are incorrect as they are not true for every patient. Option B puts the responsibility on the physician and does not provide any helpful information to the patient. Options C and E are appropriate because they provide hopeful but realistic information about the patient's ability to speak after the surgery. Option C mentions that the patient's voice may sound different, which is true due to the anatomical changes that occur with a laryngectomy. Option E acknowledges that the preservation of speech depends on the individual case and the extent of the surgery, but provides reassurance that the patient will know more after surgery.

Question 7

A patient says, "My nose is always congested, and it just seems to get worse with the nasal spray I've been using." The nurse realizes that this patient is describing which situation?

Accepted Answer

The patient is likely experiencing rebound nasal congestion, which occurs when nasal sprays are overused and the body becomes dependent on them, leading to worsening congestion when the medication wears off. The patient should be advised to stop using the nasal spray and speak with their healthcare provider about alternative treatments.

Question 8

A patient 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?

Accepted Answer

Polyps can recur after surgical removal, so it is important to have follow-up appointments to ensure they haven't returned. While insurance companies may have requirements for follow-up appointments, this is not the main reason for the recommendation. Cancerous polyps are a concern, but it is not appropriate to suggest this as a certainty without specific information about the patient's polyp. Additionally, while some health care providers may have specific protocols for follow-up appointments, this is not universal and does not provide a specific reason for the recommendation.

Question 9

While recovering at home from a total laryngectomy and neck dissection, a patient notices an increase in left shoulder weakness. This symptom is consistent with which condition?

Accepted Answer

Damage to the spinal accessory nerve can occur as a complication of neck dissection surgery, leading to weakness or paralysis of the shoulder muscles on the affected side. It is important for the patient to notify their healthcare provider of this symptom for proper evaluation and management. Normal recovery, side effects of radiation therapy, and medication complications are possible causes of other symptoms but not necessarily related to left shoulder weakness in this context.

Question 10

The nurse observes a patient's respirations during sleep and notes the absence of respirations for periods lasting from 15 to 45 seconds. This finding is consistent with which condition?

Accepted Answer

Sleep apnea is characterized by the cessation of breathing and recurrent arousals during sleep. The periods of absence of respirations lasting from 15 to 45 seconds are a common symptom of sleep apnea.

Question 11

A patient being seen for a cough tells the nurse, "After I leave here, I need to get to the dentist. My upper teeth are hurting and I don't know why." Which nursing action is indicated?

Accepted Answer

The patient's complaint of upper teeth pain could be a symptom of a sinus infection, which can cause referred pain to the teeth. The nurse should assess the patient for other signs and symptoms of a sinus infection, such as facial pressure or headache, before referring the patient to the dentist.  End the visit or rescheduling is not indicated unless the cough needs further evaluation or treatment. Telling the patient there is nothing wrong with his teeth without further assessment would be inappropriate.

Question 12

The nurse suspects that a patient is demonstrating signs of tonsillitis. Which findings are indicative of this disorder?. Select all that apply.

Accepted Answer

Tonsillitis is typically characterized by pain on swallowing, enlarged lymph nodes in the neck, and fever. Thirst and nuchal rigidity are not typically associated with this condition.

Question 13

Which patient requires the most immediate intervention by the nurse?

Accepted Answer

A patient with a maxillary fracture who has been swallowing frequently may be swallowing blood, indicating a potential airway obstruction or significant bleeding, which requires immediate intervention to ensure the airway is maintained and to prevent aspiration.

Question 14

A patient is receiving anterior nasal packing for a nosebleed. What should be included in the instructions for this patient?

Accepted Answer

Anterior nasal packing is typically left in place for 48-72 hours, but can stay up to 5 days to ensure proper hemostasis and healing.

Question 15

A patient who has diabetes complains of a tingling sensation in the face and is running a fever. Two hours later, the nurse notes dark drainage coming from the patient's nose. Which is the nurse's priority action?

Accepted Answer

The symptoms described suggest a possible complication of diabetes called cranial nerve palsy, and the dark drainage may indicate a serious bacterial infection that requires prompt treatment. Therefore, the priority action is to notify the health care provider immediately to initiate appropriate interventions. Encouraging the patient to blow the nose or administering antipyretics will not address the underlying issue, and obtaining a blood glucose level may be important but is not the priority in this situation.

Question 16

While engaging in a high school sports activity, an adolescent sustains an injury to the nose. Which finding indicates that the patient has a nasal fracture?

Accepted Answer

Periorbital ecchymosis, also known as "raccoon eyes," is a classic sign of a nasal fracture, indicating bleeding and swelling around the eyes. Shortness of breath, diaphoresis, and drop in blood pressure are not typically associated with a nasal fracture.

Question 17

The nurse is assessing a patient who has received trauma to the face. It is suspected that damage to the facial nerve (CN VIII) has occurred. The nurse would prepare this patient for which intervention?

Accepted Answer

Damage to the facial nerve can cause facial paralysis or weakness, which may require surgical intervention. This can include repairing or grafting the damaged nerve or performing a decompression procedure to relieve pressure on the nerve. Intubation, ice packs, and consultation with a dentist are not directly related to treating damage to the facial nerve.

Question 18

The nurse is providing care to a patient with a new tracheostomy. Which intervention is appropriate to include in this patient's care?. Select all that apply.

Accepted Answer

The answer of The nurse is providing care to a...

Question 19

A female patient is seen for "increased hoarseness" and a change in "voice quality." There are no other symptoms. What is an appropriate assessment for the nurse to ask this patient?

Accepted Answer

The answer of A female patient is seen for "increased...

Question 20

A patient tells the nurse he has a "cold" every spring that lasts for 8 to 10 weeks. The nurse suspects that the patient is experiencing which condition?

Accepted Answer

The patient's symptoms occurring every spring suggest a seasonal pattern, which is characteristic of allergic rhinitis. The duration of symptoms also supports this diagnosis, as acute viral rhinitis typically lasts 7-10 days, while symptoms associated with allergic rhinitis can persist for weeks to months. Vasomotor rhinitis and atrophic rhinitis are less likely diagnoses based on the patient's reported symptoms.

Quiz 26: Caring for the Patient With Upper Airway Disorders