NR341 COMPLEX ADULT HEALTH FINAL EXAM QUESTIONS AND CORRECT VERIFIED
ANSWERS |A+ GRADE
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 patentcy: ANSWER: D Airway patentcy
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.
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 blow his or her nose.
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.: ANSWER: A Collect the nasal drainage on a piece of
filter paper
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.
3. A nurse teaches a client who had a supraglottic laryngectomy. Which tech- nique
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.: ANSWER: B Swallow twice
while bearing down.
The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or
speech language pathologist teaches the client the supraglottic method of swal-
lowing. This includes placing a small amount of food in the mouth, performing the
,Valsalva maneuver, then swallowing twice. The client sits upright. The client holds the
,breath while swallowing twice. Keeping the head still and straight will not decrease
the risk of aspiration.
4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest
risk for development of obstructive sleep apnea?
a. A 26-year-old woman who is 8 months pregnant.
b. A 42-year-old man with gastroesophageal reflux disease.
c. A 55-year-old woman who is 50 lb (23 kg) overweight.
d. A 73-year-old man with type 2 diabetes mellitus.: ANSWER: C 55-year-old woman
who is 50 lb (23 kg) overweight.
The client at highest risk would be the one who is extremely overweight. None of the
other clients have risk factors for sleep apnea. Clients with sleep apnea may develop
gastroesophageal reflux.
5. A nurse cares for a client who has hypertension that has not responded well to
several medications. The client states compliance is not an issue. What action would the
nurse take next?
a. Assess the client for obstructive sleep apnea.
b. Arrange a home sleep apnea test.
c. Encourage the client to begin exercising.
d. Schedule a polysomnography: ANSWER: A Assess the client for obstructive sleep
apnea.
Hypertension not responding to medications can be a sign of obstructive sleep apnea
(OSA). The nurse would assess the client using an evidence-based tool, such as the
STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh
Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the
assessment indicate OSA may be a problem, the nurse would consult the primary
health care provider for further testing. An at-home sleep-study is often done prior to a
polysomnography. Excessive weight can contribute to OSA so exercising is always
encouraged, but this is not specific to assessing for OSA.
6. A nurse cares for a client after radiation therapy for neck cancer. The client reports
extreme dry mouth. What action by the nurse is most appropriate?
a. Ask the client to gargle with mouthwash containing lidocaine.
b. Administer IV fluid boluses every 2 hours.
c. Explain that xerostomia may be a permanent side effect.
d. Assess the client's neck for redness and swelling.: ANSWER: C Explain that
, xerostomia may be a permanent side effect.
Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the
salivary glands were in the radiation zone. Unfortunately, this may be long term or
even permanent. Gargling with lidocaine would not help. Increasing fluids is
somewhat helpful, but the client would be encouraged to drink. The client's neck
may have redness and swelling, but this finding is not related to the reported dry
mouth.
7. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client
states that all food tastes bland. How would the nurse respond?
a. "I will consult the speech therapist to ensure you are swallowing properly."
b. "This is normal after surgery. What types of food do you like to eat?"
c. "I will ask the dietitian to change the consistency of the food in your diet."
d. "Replacement of protein, calories, and water is very important after surgery.":
ANSWER: B "This is normal after surgery. What types of food do you like to eat?"
Many clients experience changes in taste after surgery. The nurse would identify
foods that the client wants to eat to ensure that the client maintains necessary nutri-
tion. Although the nurse would collaborate with the speech therapist and dietitian to
ensure appropriate replacement of protein, calories, and water, the other responses do
not address the patient's concerns.
8. A nurse cares for a client who is scheduled for a total laryngectomy. What action
would the nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.: ANSWER: C Assist the client to
choose a communication method.
The client will not be able to speak after surgery. The nurse would assist the client
to choose a communication method that he or she would like to use after surgery.
Assessing the patient's airway and administering IV pain medication are
done after the procedure. Although ambulation promotes health and decreases the
complications of any surgery, this patient's gait would not be impacted by a total
laryngectomy and therefore is not a priority
ANSWERS |A+ GRADE
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 patentcy: ANSWER: D Airway patentcy
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.
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 blow his or her nose.
c. Perform a test focused on a neurologic examination.
d. Palpate the nose, face, and neck.: ANSWER: A Collect the nasal drainage on a piece of
filter paper
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.
3. A nurse teaches a client who had a supraglottic laryngectomy. Which tech- nique
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.: ANSWER: B Swallow twice
while bearing down.
The client post supraglottic laryngectomy has a high risk for aspiration. The nurse or
speech language pathologist teaches the client the supraglottic method of swal-
lowing. This includes placing a small amount of food in the mouth, performing the
,Valsalva maneuver, then swallowing twice. The client sits upright. The client holds the
,breath while swallowing twice. Keeping the head still and straight will not decrease
the risk of aspiration.
4. A nurse assesses clients on the medical-surgical unit. Which client is at greatest
risk for development of obstructive sleep apnea?
a. A 26-year-old woman who is 8 months pregnant.
b. A 42-year-old man with gastroesophageal reflux disease.
c. A 55-year-old woman who is 50 lb (23 kg) overweight.
d. A 73-year-old man with type 2 diabetes mellitus.: ANSWER: C 55-year-old woman
who is 50 lb (23 kg) overweight.
The client at highest risk would be the one who is extremely overweight. None of the
other clients have risk factors for sleep apnea. Clients with sleep apnea may develop
gastroesophageal reflux.
5. A nurse cares for a client who has hypertension that has not responded well to
several medications. The client states compliance is not an issue. What action would the
nurse take next?
a. Assess the client for obstructive sleep apnea.
b. Arrange a home sleep apnea test.
c. Encourage the client to begin exercising.
d. Schedule a polysomnography: ANSWER: A Assess the client for obstructive sleep
apnea.
Hypertension not responding to medications can be a sign of obstructive sleep apnea
(OSA). The nurse would assess the client using an evidence-based tool, such as the
STOP-Bang Sleep Apnea Questionnaire, the Epworth Sleepiness Scale, the Pittsburgh
Sleep Quality Index, and the Multiple Sleep Latency Test. If the results of the
assessment indicate OSA may be a problem, the nurse would consult the primary
health care provider for further testing. An at-home sleep-study is often done prior to a
polysomnography. Excessive weight can contribute to OSA so exercising is always
encouraged, but this is not specific to assessing for OSA.
6. A nurse cares for a client after radiation therapy for neck cancer. The client reports
extreme dry mouth. What action by the nurse is most appropriate?
a. Ask the client to gargle with mouthwash containing lidocaine.
b. Administer IV fluid boluses every 2 hours.
c. Explain that xerostomia may be a permanent side effect.
d. Assess the client's neck for redness and swelling.: ANSWER: C Explain that
, xerostomia may be a permanent side effect.
Xerostomia, or dry mouth, is a potential side effect of radiation, particularly if the
salivary glands were in the radiation zone. Unfortunately, this may be long term or
even permanent. Gargling with lidocaine would not help. Increasing fluids is
somewhat helpful, but the client would be encouraged to drink. The client's neck
may have redness and swelling, but this finding is not related to the reported dry
mouth.
7. A nurse cares for a client who had a partial laryngectomy 10 days ago. The client
states that all food tastes bland. How would the nurse respond?
a. "I will consult the speech therapist to ensure you are swallowing properly."
b. "This is normal after surgery. What types of food do you like to eat?"
c. "I will ask the dietitian to change the consistency of the food in your diet."
d. "Replacement of protein, calories, and water is very important after surgery.":
ANSWER: B "This is normal after surgery. What types of food do you like to eat?"
Many clients experience changes in taste after surgery. The nurse would identify
foods that the client wants to eat to ensure that the client maintains necessary nutri-
tion. Although the nurse would collaborate with the speech therapist and dietitian to
ensure appropriate replacement of protein, calories, and water, the other responses do
not address the patient's concerns.
8. A nurse cares for a client who is scheduled for a total laryngectomy. What action
would the nurse take prior to surgery?
a. Assess airway patency, breathing, and circulation.
b. Administer prescribed intravenous pain medication.
c. Assist the client to choose a communication method.
d. Ambulate the client in the hallway to assess gait.: ANSWER: C Assist the client to
choose a communication method.
The client will not be able to speak after surgery. The nurse would assist the client
to choose a communication method that he or she would like to use after surgery.
Assessing the patient's airway and administering IV pain medication are
done after the procedure. Although ambulation promotes health and decreases the
complications of any surgery, this patient's gait would not be impacted by a total
laryngectomy and therefore is not a priority
