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.
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Related Questions
Correct Answer is D
Explanation
A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.
B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.
C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.
D. Use distractions when bathing the client.Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.
Correct Answer is B
Explanation
If a nurse hangs a bag of dextrose 5% in water, 1,000 mL at 0800 to run at 125 mL/hr and notices that the client's IV bag is empty at 1200, the first intervention the nurse should take is to assess the client's vital signs. This will help the nurse determine if the client is experiencing any adverse effects from the rapid infusion of fluids.
Option a is incorrect because notifying the primary care provider is important but not the first intervention.
Option c is incorrect because calculating the infused volume is important but not the first intervention.
Option d is incorrect because completing an incident report is important but not the first intervention.
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