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.
The Correct Answer is D
A. Explain the techniques of esophageal speech. Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.
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. This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.
D. Review the use of an artificial larynx with the client. This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is that the nurse should place the base of a vibrating tuning fork on the top of the client's head when performing Weber's test. Weber's test is a screening test for hearing that can detect unilateral (one-sided. conductive hearing loss (middle ear hearing loss) and unilateral sensorineural hearing loss (inner ear hearing loss)².
Options b, c and d are not correct actions for performing Weber's test. Counting how many seconds a client can hear a tuning fork after it has been struck, placing the base of a vibrating tuning fork on the client's mastoid process and moving a vibrating tuning fork in front of the client's ear canals one after the other are not part of Weber's test.
Correct Answer is A
Explanation
When providing change-of-shift report about a client who has shingles, the nurse should include information about the type of transmission-based precautions in place to prevent the spread of infection to other clients and staff. Shingles is caused by the varicella-zoster virus and can be spread through direct contact with the rash.
- The times for routine vital sign measurements may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The client's background health history may be important information to include in the report, but it is not specific to the client's condition of shingles.
- The number of visitors the client had during the shift may be important information to include in the report, but it is not specific to the client's condition of shingles.
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