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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When planning an educational conference about informed consent, the nurse should include information about the potential risks of the procedure. Informed consent is a process in which the client is provided with information about a medical procedure or treatment, including its potential risks and benefits, so that they can make an informed decision about whether to proceed.
Option a is incorrect because after signing the informed consent, the client still has the right to refuse the procedure.
Option c is incorrect because it is not the nurse's responsibility to explain the procedure when obtaining informed consent; this is typically done by the healthcare provider performing the procedure.
Option d is incorrect because a nursing student cannot witness an informed consent; only a licensed healthcare professional can do so.
Correct Answer is A
Explanation
As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and flexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.
- Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be influenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
- Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
- Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.
In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.
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