A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?
Explain the techniques of esophageal speech.
Schedule a support session for the client.
Determine the client's reading ability.
Review the use of an artificial larynx with the client.
None
None
The Correct Answer is C
A. Explain the techniques of esophageal speech. Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.
B. Schedule a support session for the client. While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.
C. Determine the client's reading ability. After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.
D. Review the use of an artificial larynx with the client. An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a) This response may seem dismissive of the partner’s immediate concern about the DNR order and does not directly address their request.
b) While this response attempts to establish a connection through shared experience, it may shift the focus away from the partner's feelings and can come off as self-centered. It may also invalidate the partner's unique experience of loss.
c) This response acknowledges the emotional distress and difficulty the partner is experiencing while validating their feelings. It shows empathy and understanding, which can help build rapport and encourage further communication about the situation.
d)This response is inappropriate because it does not respect the existing DNR order and could create confusion or frustration for the partner. Additionally, changing a DNR order requires specific processes and discussions with the healthcare team.
Correct Answer is D, B, A, C
Explanation
When caring for a client who is nauseated and unable to eat after taking an antibiotic, the nurse should first identify possible nursing interventions that address the client's nausea. The nurse should then review the potential benefits and consequences of each intervention. The nurse should determine the probability of intervention-related complications. Finally, the nurse should select an intervention that provides the greatest benefit and least risk to the client.
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