A nurse is caring for a client two months following a total laryngectomy. The nurse should recognize that which of the following statements made by the client indicates the need for further teaching?
"My sense of smell is taking a long time to return."
"Breathing through my stoma has diminished my sense of smell."
"I can't smell what I eat, but hope to enjoy eating in the future."
"I am happy to have a mild sense of taste despite no sense of smell."
The Correct Answer is A
A. "My sense of smell is taking a long time to return.": This statement indicates a misunderstanding because, after a total laryngectomy, the sense of smell is significantly impaired or lost due to the inability to breathe through the nose. The client needs further teaching to understand that this change is likely permanent.
B. "Breathing through my stoma has diminished my sense of smell.": This statement is accurate as the stoma bypasses the nasal passages, reducing the sense of smell.
C. "I can't smell what I eat, but hope to enjoy eating in the future.": This shows an understanding that the sense of smell is impaired but expresses a positive outlook on enjoying food in other ways.
D. "I am happy to have a mild sense of taste despite no sense of smell.": This statement indicates an understanding of the sensory changes post-laryngectomy and reflects realistic expectations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Constipation: Constipation is not a common adverse effect of Atenolol, which is a beta- blocker.
B. Cough: Cough is more commonly associated with ACE inhibitors rather than beta-blockers like Atenolol.
C. Tremor: Tremor is not typically an adverse effect of Atenolol; beta-blockers can actually be used to treat essential tremors.
D. Bradycardia: Atenolol, as a beta-blocker, can slow the heart rate, leading to bradycardia, which is a well-documented adverse effect.
Correct Answer is C
Explanation
A. The client has circumoral cyanosis: Circumoral cyanosis, or bluish discoloration around the mouth, is a sign of hypoxia but may not be present in all cases of hypoxemia. Pulse oximetry provides a more objective measurement.
B. The client's heart rate is 86 bpm: Heart rate may be within normal limits even in the presence of hypoxemia, as compensatory mechanisms may not be fully activated.
C. The client has a pulse ox of 90% on room air: A pulse oximetry reading of 90% indicates hypoxemia (oxygen saturation below normal levels), which is a significant finding, especially in a client with COPD who may already have compromised respiratory function.
D. The client is lethargic: Lethargy may occur with severe hypoxemia, but it is a late sign and may not always be present. Monitoring oxygen saturation is more reliable for early detection of hypoxemia.
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