A nurse is caring for an adult client.

Exhibits

The nurse should determine the assessment findings are consistent with which of the following disease processes?

For each assessment finding, click to specify if the assessment finding is consistent with laryngotracheobronchitis (LTB), epiglottitis, or foreign body aspiration. Each finding may support more than 1 disease process.

Respiratory rate

Irritability

Drooling

Fever

Immunization status

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B,C"},"C":{"answers":"B,C"},"D":{"answers":"A,B"},"E":{"answers":"B"}}

Respiratory Rate: LTB, Epiglottitis, Foreign Body Aspiration. An increased respiratory rate (tachypnea) is common in both conditions due to airway obstruction and respiratory distress. In epiglottitis, inflammation and swelling of the epiglottis severely restrict airflow, leading to tachypnea. Similarly, foreign body aspiration can cause partial obstruction, increasing respiratory effort and rate. Increased respiratory rate is a significant finding in LTB due to airway narrowing and respiratory distress. The body compensates for the partial airway obstruction by increasing ventilation. However, tachypnea in LTB is usually not as severe as in epiglottitis or foreign body aspiration, where airway obstruction is more critical.
Irritability: LTB, Epiglottitis, Foreign Body Aspiration. Irritability is a common symptom in all three conditions due to hypoxia and respiratory distress. In LTB (croup), inflammation leads to airway narrowing, causing discomfort and restlessness. In epiglottitis, the rapid onset of airway swelling results in agitation. Foreign body aspiration also causes significant distress due to the sudden obstruction of airflow.
Drooling: Epiglottitis, Foreign Body Aspiration. Drooling is characteristic of epiglottitis because the client cannot swallow due to severe throat pain and airway swelling. It is also seen in foreign body aspiration when an object is lodged in the airway or esophagus, making swallowing difficult. Drooling is not a typical feature of LTB, where coughing and stridor are more prominent.
Fever: LTB, Epiglottitis. Both LTB and epiglottitis are caused by infections and present with fever. In LTB, viral infections like parainfluenza commonly cause a low-to-moderate fever. Epiglottitis, often caused by bacterial infections such as Haemophilus influenzae type B (Hib), typically presents with a high fever, as seen in this case. Foreign body aspiration is not associated with fever unless secondary infection develops.
Immunization Status: Epiglottitis. Epiglottitis is strongly linked to Haemophilus influenzae type B (Hib), a bacteria preventable by routine childhood vaccination. In unvaccinated individuals or those with incomplete immunization, epiglottitis is more likely to occur. Immunization status does not directly correlate with LTB (which is viral) or foreign body aspiration.

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Correct Answer is B

Explanation

A. "Your body will slowly develop an ability to smell through your stoma." The olfactory system relies on air passing through the nasal passages to detect scents. After a total laryngectomy, the airway is rerouted through a stoma, bypassing the nose entirely. The body does not develop an alternative way to smell through the stoma, making this statement inaccurate.
B. "Breathing through a stoma has altered your sense of smell." A total laryngectomy permanently separates the respiratory and digestive tracts, preventing air from passing through the nose, which is necessary for olfaction. As a result, clients often experience anosmia (loss of smell). This response accurately explains the reason behind the alteration in the client’s sense of smell.
C. "Your sense of smell will gradually return after several months." Unlike temporary post-surgical changes, the loss of smell after a total laryngectomy is typically permanent unless the client learns to use techniques such as the "polite yawning" method (nasal airflow-inducing maneuver) to regain some olfactory function. It does not naturally return over time.
D. "As your appetite returns, your sense of smell will also return." Appetite and sense of smell are closely linked, but appetite improvement does not restore olfaction after a laryngectomy. Since air no longer flows through the nasal passages, the ability to detect smells is significantly impaired or lost.

Correct Answer is ["4"]

Explanation

Formula:

Volume to administer (mL) = (Desired dose (mg) / Available concentration (mg/mL))

Desired dose = 1.6 mg

Available concentration = 2 mg / 5 mL

Calculate the concentration per mL:

2 mg / 5 mL = 0.4 mg/mL

Volume to administer = 1.6 mg / 0.4 mg/mL

= 4 mL

The nurse should administer 4 mL per dose.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports experiencing alteration in sense of smell following surgery for a total laryngectomy. The nurse should address the client's concern through which of the following response?

Correct Answer is B

Explanation

A nurse is preparing to administer albuterol syrup 1.6 mg PO tid. Available is albuterol 2 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["4"]

Explanation

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