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 A
Explanation
A. Tachypnea: Tachypnea, or rapid breathing, is a common symptom of pulmonary embolism. It occurs as the body attempts to compensate for decreased oxygenation and increased carbon dioxide levels resulting from impaired blood flow to the lungs. Tachypnea helps to improve gas exchange by increasing ventilation.
B. Wet cough: A wet or productive cough may occur in conditions such as pneumonia or chronic bronchitis but is not typically associated with pulmonary embolism. Pulmonary embolism is more commonly characterized by symptoms such as dyspnea, chest pain, and tachypnea.
C. Dull chest pain: Chest pain associated with pulmonary embolism is often sharp and pleuritic, meaning it worsens with deep breathing or coughing. It may be described as stabbing or like a "knife-like" sensation. Dull chest pain is not a typical finding in pulmonary embolism.
D. Episodes of apnea: While severe cases of pulmonary embolism can lead to respiratory failure and apnea, it is not a common presenting symptom. Most clients with pulmonary embolism will exhibit tachypnea as a compensatory mechanism to maintain adequate oxygenation.
Correct Answer is B
Explanation
A. The duration of contact with the agent: While duration is important, it alone does not provide a comprehensive understanding of radiation burns, which require considering the type and dose of radiation as well.
B. The type, dose, and length of exposure: These factors are crucial in assessing the severity and necessary treatment for radiation burns. The type of radiation (e.g., alpha, beta, gamma), the dose
received, and the length of exposure all determine the extent of tissue damage and appropriate interventions.
C. The pathway of flow through the body: This is more relevant to internal contamination with radioactive substances rather than external radiation burns.
D. The temperature to which the skin is heated: Temperature is a factor in thermal burns, not radiation burns. Radiation burns result from energy transfer, not heat.
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