NUR 2502 MDC 3 EXAM 2 100% VERIFIED FALL 2022. Graded A

NUR 2502 MDC 3 EXAM 2 100% VERIFIED FALL 2022 hyperventilation, if someone is blowing off too much CO2 they become more Correct Answer- Alkaline, respiratory alkalosis if a patient's lung are not functioning very well ...

NUR 2502 MDC 3 EXAM 2 100% VERIFIED FALL 2022 hyperventilation, if someone is blowing off too much CO2 they become more Correct Answer- Alkaline, respiratory alkalosis if a patient's lung are not functioning very well and they are unable to remove or blow off CO2 very well, the CO2 will build up in their system becoming Correct Answer- acidic, respiratory acidosis Perfusion Correct Answer- is adequate arterial blood flow through the peripheral tissues (peripheral perfusion) and blood that is pumped by the heart to oxygenate major body organs (central perfusion) upper respiratory tract Correct Answer- nose, sinuses, pharynx, larynx Lower respiratory tract Correct Answer- Lungs,Trachea, two mainstem bronchi, lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; alveoli common cause of respiratory ailments Correct Answer- Cigarette smoke Nursing care of a patient experiencing upper respiratory system disorders Correct Answer- maintaining a patent airway to allow adequate ventilation and oxygenation. Along with a focused respiratory assessment, the nurse will utilize information obtained from the patient and family during the admission history interview. Information regarding the patient's history of upper respiratory disorders, smoking, and environmental exposures will be utilized to determine the necessary testing and treatment Normal Changes in Aging Adults Correct Answer- Alveoli function decreases Ability to cough decreases Lungs loose residual volume, vital capacity and gas exchange decreases. Respiratory muscles atrophy Vascular resistance increases, capillary flow decreases Susceptibility to infection increases.The turbinates Correct Answer- three bones that protrude into the nasal cavities from the internal portion of the nose increase the total surface area for filtering, warming, and humidifying inspired air before it passes into the nasopharynx. The paranasal sinuses Correct Answer- air-filled cavities within the bones that surround the nasal passages Lined with ciliated membrane, the sinuses provide resonance to speech, decrease the weight of the skull, and act as shock absorbers in the event of facial trauma.. Fremitus refers to vibratory tremors that can be felt through the chest by palpation, Increased fremitus may indicate Correct Answer- compression or consolidation of lung tissue, as occurs in pneumonia. Lung sounds Correct Answer- Bronchial Bronchovesicular Vesicular Adventitious sounds Correct Answer- Crackles Wheezes Rhonchus Pleural friction rub Other Indicators of Respiratory Adequacy Correct Answer- Cyanosis, decreased capillary refill, clubbing of nails in fingers, level of consciousness, Chest Circumference, Anxiety, Dyspnea Orthopnea, General Appearance Diagnostic Assessment of lungs Correct Answer- Laboratory assessment - RBC - ABG- is a blood gas and this tells us the acid base balance of the patient - Sputum- can tell us if microorganisms are growing in the lung - describe color, clarity, and any odorImaging assessment - x-rays-Xrays show us areas of opaque which usually indicate pneumonia/consolidation of fluid -CT- computed tomography. Lung nodules, areas of fluid buildup Other noninvasive diagnostic assessments - Pulse oximetry-circulating O2- tells us oxygen levels in the tissues- usually fingers, toes, or earlobes - Capnometry and capnography-how much CO2 is leaving the lungs. -PFTs-Lung function- tell us how well the lungs function at moving air in and out - Exercise testing-Exercise tolerance Invasive Diagnostic Assessment Correct Answer- -Endoscopic examinations -Bronchoscopy- is a camera that looks at the airway passages -Thoracentesis- can remove fluid buildup from the lung -Lung biopsy- is used to diagnose some lung diseases or cancer Which assessment finding for an older adult patient does the nurse ascribe to the natural aging process? Correct Answer- A.Tightening of the vocal cords B.Decrease in residual volume C.Decrease in the anteroposterior diameter D.Decrease in respiratory muscle strength D. As a person ages, vocal cords become slack, changing the quality and strength of the voice; the anteroposterior diameter increases; respiratory muscle strength decreases; and the residual volume increases. The nurse knows that under normal physiologic conditions of tissue perfusion, a patient will have what percent of oxygen dissociate from the hemoglobin molecule? Correct Answer- A.25% B.50%C.75% D.100% ANS: B Oxygen dissociates with the hemoglobin molecule based on the need for oxygen to perfuse tissues. Under normal conditions, 50% of hemoglobin molecules completely dissociate their oxygen molecules when blood perfuses tissues that have an oxygen tension (concentration) of 26 mm Hg. This is considered a "normal" point at which 50% of hemoglobin molecules are no longer saturated with oxygen. Which assessment finding does the nurse interpret that is associated most closely with lung disease? Correct Answer- A.Cough B.Dyspnea C.Chest pain D.Sputum production ANS: A Cough is a main sign of lung disease. Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. A patient's feeling of dyspnea may not be consistent with the severity of the presenting problem. Sputum production may be associated with coughing and indicate an acute or chronic lung condition. Chest pain can occur with other health problems, as well as with lung problems. Head and Neck Cancer Correct Answer- Squamous cell carcinoma and slow growing Begins with mucus that is chronically irritated, becoming tougher and thicker Leukoplakia and erythroplakia lesions Spreads to local lymph nodes, muscle and bone, then to liver or lungs. Risks of head and neck cancer Correct Answer- •Tobacco use •Alcohol use •Voice abuse•Chronic laryngitis •Exposure to chemicals •Poor hygiene •Long-term gastroesophageal reflux disease •Oral infections with human papillomavirus Assessment: Noticing- head and neck cancer Correct Answer- Lumps in mouth, throat, neck Difficulty swallowing Color changes in mouth or tongue Oral lesion or sore that does not heal in 2 weeks Persistent, unilateral ear pain Persistent/unexplained oral bleeding Numbness of mouth, lips, or face Change in fit of dentures Hoarseness or change in voice quality Persistent/recurrent sore throat Shortness of breath Anorexia and weight loss Change in fit of dentures Burning sensation when drinking citrus or hot liquids The priority interprofessional collaborative problems for patients with head and neck cancer include Correct Answer- Potential for airway obstruction Potential for aspiration Anxiety Decreased self esteem Planning and Implementation: Responding Head and Neck Cancer Correct Answer- Radiation therapy has a cure rate of at least 80%hoarseness, dysphagia, skin problems, impaired taste, and dry mouth for a few weeks after radiation therapy. Chemotherapy Varies based on type of cancer cells: usually Cistplatin Intensify oral cavity side effects Cordectomy Vocal Cord Removal Laryngectomy Complete or partial removal of the Larynx and surrounding area. Laryngectomy Postoperative Care Correct Answer- First priorities are airway maintenance and ventilation Wound, flap, reconstructive tissue care Hemorrhage Wound breakdown Pain management Nutrition Speech and language rehabilitation. Cancer of the Nose & Sinuses Correct Answer- Tumors rare, benign or malignant- asian Americans higher incidence of nasal cancer. Seen with exposure to dust from wood, textiles, leather, flour, nickel, chromium mustard gas, radium Slow onset, resembles sinusitis Lymph enlargement often occurs on side with tumor mass Surgical removal is treatment; may be combined with radiation (IMRT) the same interventions listed under the section for patients with head and neck cancersFracture of the Nose Correct Answer- Displacement of bone or cartilage can cause airway obstruction or cosmetic deformity; potential source of infection CSF may indicate skull fracture Interventions Closed reduction Rhinoplasty Nasoseptoplasty Causes: •Contact sports •Fights •Motor vehicle accidents Postoperative Careafter Rhinoplasty Correct Answer- Observe for edema and bleeding Check vital signs every 4 hours Change drip pad as needed Encourage patient to remain in a semi-fowlers position. Decrease any forcefully coughing or straining. •Maintaining a semi-Fowler's position to reduce swelling. •Application of cool compresses to reduce pain and swelling. •Educate the patient not to cough forcefully or strain for the first few days to prevent possible bleeding. Monitor nasal packing for increased bleeding Facial Trauma Correct Answer- can involve the mandible, maxillary, orbital, and nasal bones and the side of the face. Trauma to the mandible is classified as Le Fort I, II, and III. Le Fort III can result in extensive bleeding and bruising and result in airway obstruction that impacts gas exchange.Priority action is airway assessment - Manifestations Stridor Shortness of breath/dyspnea Anxiety/restlessness Hypoxia and hypercarbia Decreased oxygen saturation Cyanosis, loss of consciousness Epistaxis Correct Answer- Nosebleed is a common problem Trauma Hypertension Chronic Cocaine Use Cauterization of affected capillaries may be needed; nose is packed Posterior nasal bleeding is an emergency! Assess for respiratory distress, tolerance of packing or tubes Humidification, oxygen, bed rest, antibiotics, pain medications Position patient upright and leaning forward Pinch bridge of the nose (pressure) Cold Compress (vasoconstriction) Nasal Packing if necessary •Nursing care of a patient with epistaxis includes: •Management of bleeding by applying direct lateral pressure to the nose for 10 minutes and the application of ice or cool compresses. If bleeding does not cease, nasal packing may be applied.•Implement standard precautions. •Educate the patient to maintain an upright position, such as leaning forward to prevent aspiration. •Monitor blood pressure to prevent periods of hypertension, which could increase the chance of bleeding. •Instruct the patient not to blow his or her nose for 24 hours to prevent clot disruption. •Avoid straining, bending over, blowing nose forcefully Interprofessional Collaborative Care Facial Trauma Correct Answer- Airway assessment Anticipate need for emergency intubation Tracheotomy Cricothyroidotomy Fixed occlusion Débridement If a patent airway is not able to be secured, the patient may require an emergency intervention such as a tracheotomy or cricothyroidotomy. The next priorities are controlling hemorrhage, identification of the source of bleeding, and providing aggressive fluid resuscitation to maintain patient stability. Patients who present with facial trauma also require stabilization of the head and neck until the extent of the injury can be determined. Maintain cervical alignment until diagnostic tests have cleared the patient of injury. Patients who suffer from facial trauma often require surgical intervention for the injuries, nursing care of these patients includes monitoring airway, assessing for bleeding and infection, and providing patient education on oral care. Depending on the extent of the injury, the patient will likely have their jaw wired. Educate the patient and family on the use of a wire cutter for emergency situations. obstructive sleep apnea (OSA) Correct Answer- cessation in breathing while sleeping. Must occur a minimum of 5x/hour (can be hundreds/night) lasts from 10sec - greater than 1 minute with each episode Risk factors of obstructive sleep apnea (OSA) Correct Answer- Obesity Oropharyngeal edema Family history Hypothyroidismshort neck with recessed chin Enlarged tonsils, adenoids, uvula Cigarette smoking and alcohol or sedative use Complications of sleep Apnea Correct Answer- HTN Stroke Cognitive deficits Weight gain Diabetes Pulmonary disease Cardiovascular disease Excessive daytime sleepiness, irritability, inability to concentrate Diagnostic Tests for sleep apnea Correct Answer- STOP-Bang Sleep Apnea Questionnaire ABG and TSH level Sleep study: observation and measurement of the client during sleep. T/X sleep apnea Correct Answer- Treatment Lose weight if sleep apnea is caused by obesity Refrain from alcohol or sedatives Avoid sleeping on your back (position fixing) Noninvasive positive-pressure ventilation (NPPV) BiPap CPAP APAP Modafinil (Attenance,Provigil) Surgery Adenoidectomy- to remove excess tissueUvulopalatopharyngoplasty (UPPP)- done for those with enlarged tissues- remodels posterior oropharynx Tracheostomy- bypasses obstruction. Done for those with severe OSA or those who cannot tolerate the CPAP upper airway obstruction Correct Answer- Airflow blockage in the nose, mouth, pharynx, or larynx caused by: trauma blockages/masses burns foreign bodies Medical emergency!! Prompt action is required to prevent further patient compromise. Interventions are based on the patient's presenting signs and symptoms and the cause of the obstruction. If the patient is conscious, perform the Heimlich maneuver. If the patient is unconscious, open the airway by repositioning the head or inserting an oral airway. Suction the patient to remove secretions and perform abdominal thrust. If the obstruction is not able to be cleared, the patient may require an emergency tracheotomy, cricothyroidotomy, or endotracheal intubation. A 58-year-old woman who has been diagnosed with throat cancer 1 week ago comes to the clinic today to discuss surgical options with her health care provider. She is very tearful and appears sad when the nurse calls her back to the examination room. Based on her diagnosis, which clinical manifestation will the nurse likely observe in the patient? Correct Answer- A.Hoarseness B.Severe chest pain C.Low hemoglobin level (anemia) D.Numbness and tingling of the face ANS: AThe patient may experience several different symptoms. The most commonly seen with throat cancer is hoarseness, as well as mouth sores or a lump in the neck. Anemia can result if surgery is performed. Severe pain in the chest can be associated with many different disorders and is not usually linked to throat cancer. Numbness and tingling of the face cannot be observed. S/Sx of throat cancer: hoarsness, soar throat, difficulty swallowing, mouth sores, ear pain, oral bleeding When the nurse begins taking the patient's history, the patient asks, "Did you know that I have throat cancer and may not survive?" What is the appropriate nursing response? A."Are you having difficulty swallowing?" B."My mother had cancer, so I know how you must be feeling right now." C."I am sure that your cancer can be cured if you follow your doctor's advice." D."I know you have been diagnosed with cancer. Are you concerned about what the future may hold?" Correct Answer- ANS: D Although option A is part of an appropriate history, the patient's need at the moment, represented by her statement, is psychosocial in nature. The nurse should realize that the patient may need psychosocial support. This is the only appropriate therapeutic response. The nurse cannot give her false reassurance (option C), and the nurse should never compare feelings (option B). Head and neck cancer is curable when treated early. The provider discusses radiation therapy with the patient because her lesion is small and the cure rate is 80% or higher. The patient asks if her voice will return to normal. What is the appropriate nursing response? (Select all that apply.) A."At first the hoarseness may become worse." B."The more you use your voice, the quicker it will improve." C."Gargling with saline may help decrease the discomfort in your throat." D."Your voice will improve within 4 to 6 weeks after completion of the therapy." E."You should rest your voice and use alternative communication during the therapy." Correct AnswerANS: A, C, D, EThe patient should be taught not to use her voice more than necessary during and after therapy, and to work with family to determine alternative forms of communication until after the radiation therapy. Statements A, C, D, and E are appropriate responses that accurately reflect the normal course of progression after radiation therapy for throat cancer. After the radiation therapy begins, the patient visits the clinic stating that her throat is sore, she is having difficulty swallowing, and the skin on her throat is red, tender, and peeling. What patient teaching should the nurse provide? Correct Answer- ANS: For temporary relief of the patient's sore throat and swallowing difficulty, suggest that she gargle with saline, suck on ice chips, use mouthwash, or use a throat spray with local anesthetics such as lidocaine. For her red, tender, peeling skin, have her avoid exposure to sun, heat, cold, or abrasive treatments such as shaving; wear protective clothing of soft cotton; wash gently with mild soap; and use only lotions or powders prescribed by the radiation oncologist until the area has healed. The nurse is caring for a patient admitted for treatment of neck and throat cancer. Which intervention should the nurse perform? A.Encourage hydration with water. B.Feed the patient if coughing occurs. C.Encourage the patient to sit in a chair for meals. D.Encourage the patient to drink juice to address thirst. Correct Answer- ANS: C • Several interventions are necessary to reduce the risk of aspiration. Having the patient sit upright to eat is an important initial step to reduce aspiration. Other interventions include encouraging liquids that are "thick." Avoiding thin liquids like juice, water, and fruits that produce juice are important strategies to reduce aspiration risks. Coughing may be a sign of difficulty with swallowing or aspiration and requires additional assessment. What can happen if a pt aspirates? What are they at risk for? What are other ways we can reduce aspiration risk? (speech consult, to chair or HOB all they way up, slow eating) The nurse is caring for a patient admitted to the ED after experiencing a fall while rock climbing. The patient has several facial fractures. Which objective assessment finding requires immediate intervention?A.Malaligned nasal bridge B.Blood draining from one of the nares C.Crackling of the skin (crepitus) upon palpation D.Clear glucose positive fluid draining from nares Correct Answer- ANS: D • Blood or clear fluid (cerebrospinal fluid, or CSF) may drain from one or both nares. However, the presence of glucose in the clear drainage indicates that CSF is draining, which could be caused by a skull fracture, a serious complication CSF leak- yellow ring on testing strips. A malaligned nasal bridge and crepitus may be observed when evaluating general facial fractures and would be considered an expected finding. What would be the priority for this patient? Open airway The nurse recognizes that a patient with sleep apnea may benefit from which intervention(s)? (Select all that apply.) A.Weight loss B.Nasal mask to deliver BiPAP C.A change in sleeping position D.Medication to increase daytime sleepiness E.Position-fixing device that prevents tongue subluxation Correct Answer- ANS: A, B, C, E All interventions listed are viable interventions that can be of benefit to patients who have sleep apnea. Patients should work with their providers of care to determine the severity of their sleep apnea and which specific interventions would be of most importance to them. Encouraging daytime sleepiness is the opposite of the effect needed for this patient. What are the signs of sleep apea/who is at risk? Overweight, large neck size, short neckObesity Oropharyngeal edema Family history Hypothyroidism short neck with recessed chin Enlarged tonsils, adenoids, uvulaCigarette smoking and alcohol or sedative use Complications: HTN Stroke Cognitive deficits Weight gain Diabetes Pulmonary disease Cardiovascular disease Excessive daytime sleepiness, irritability, inability to concentrate Treatment:Lose weight if sleep apnea is caused by obesity Refrain from alcohol or sedatives Avoid sleeping on your back (position fixing) Noninvasive positive-pressure ventilation (NPPV) With which client does the nurse anticipate complications from obstructive sleep apnea following abdominal surgery? A. 28-year-old who is 80 lbs (36.4 kg) overweight and has a short neck B. 48-year-old who has type 1 diabetes and chronic sinusitis C. 58-year-old who has had gastroesophageal reflux disease for 10 years D. 78-year-old who wears upper and lower dentures and has asthma Correct Answer- •A - overweight and short neck •Age doesn't really matter Mr. Sherwood is a 27-year-old male who had a fractured nose and is recovering from a rhinoplasty. He has a moustache dressing in place that is dry and intact. The nurse observes that the patient is swallowing repeatedly. What complication does the nurse anticipate? What equipment does the nurse need to assess Mr. Sherwood? Correct Answer- - Posterior nasal bleeding; penlight•Rationale: Assessing how often the patient swallows after nasal surgery is a priority because repeated swallowing may indicate posterior nasal bleeding. A penlight is used to examine the throat for bleeding. Mr. Sherwood is concerned because his nose keeps bleeding. He asks the nurse, "Can you tell me again what I can do to keep my nose from bleeding?" How should the nurse respond to Mr. Sherwood's question? Mr. Sherwood is discharged home. The nurse talks with him and his family on how to care for Mr. Sherwood after discharge. What are some talking points that the nurse should include in discharge teaching for Mr. Sherwood and his family? Correct Answer- •Answer: The nurse may suggest that the patient keep his mouth open while sneezing, not bend over, and avoid coughing and vomiting. Avoid taking aspirin and NSAIDs while the nose heals. Avoid straining during bowel movements. •Rationale: These activities increase blood pressure causing fragile blood vessels to break and bleed. Teaching the patient to avoid these activities will prevent increase in pressure. Laxatives or stool softeners may help to ease bowel movements. Aspirin and NSAIDs increase bleeding potential. • •The nurse may include instructing the patient to stay in a semi-Fowlers' position, to move slowly, to keep all follow-up appointments, to call his provider if fever develops, and to use a humidifier. •Rationale: Providing discharge instructions to Mr. Sherwood and his family allows them to be involved in his care and increases compliance and health care outcomes. Correct positioning and moving slowly decrease chances of bleeding and edema to the area. Following up with the provider allows opportunity for extension of care to complete recovery and identification of problems early. Asthma occurs in two ways: Correct Answer- •Inflammation •Airway hyperresponsiveness leading to bronchoconstriction Asthma is classified based on how well controlled the symptoms are and the patient's response to the medications to treat the disease process. Status asthmaticus is a severe life-threatening condition that requires prompt interventionPathophysiology of asthma Correct Answer- •Intermittent and reversible airflow obstruction affecting airways only, not alveoli Airway obstruction •Inflammation •Airway hyperresponsiveness causes of asthma Correct Answer- exposure to allergens or irritants; stress, cold, and exercise Interprofessional Collaborative Care for asthma Correct Answer- Assessment: Noticing •Physical assessment/clinical manifestations •Audible wheeze, increased respiratory rate •Increased cough •Use of accessory muscles •"Barrel chest" from air trapping •Long breathing cycle •Cyanosis •Hypoxemia Symptoms- labored breathing, wheezing, trouble sleeping, frequent cough, feeling tired, feeling short of breath Common triggers - pollution, dust, smoke, pet dandner, household chemicals, bacteria, viruses, mold Assessment: Noticing for asthma Correct Answer- Laboratory assessment •ABGs Pulmonary function tests •Forced vital capacity (FVC) •Forced expiratory volume in first second (FEV1)•Peak expiratory flow rate (PEFR) Interventions: Responding to Asthma Correct Answer- 1.Self-management education •Personal asthma action plan •Control and prevent flair-ups. •Avoid Triggers •Use of Peak-flow meter 2.Drug therapy •Control therapy drugs (used daily) •Reliever drugs (used to stop an attack)