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 B
Explanation
The correct answer is that the nurse should include information about the effectiveness of the last dose of pain medication in the hand-off report when transferring a client to a long-term care facility. This information is important for the receiving facility to continue managing the client's pain effectively.
Options a, c and d are not essential information to include in the hand-off report. The time of the client's last bath, the number of family members who have visited and the frequency of previous vital sign measurement are not critical for ensuring continuity of care during the transfer.
Correct Answer is A
Explanation
Decreased judgment is a common sign of sleep deprivation. When a person is sleep deprived, their cognitive function can be impaired, leading to difficulty making decisions and exercising good judgment.
Options b, c, and d are not necessarily indicative of sleep deprivation. Decreased activity can be a sign of many different conditions, including fatigue or depression. Increased reflexes and increased auditory alertness are not commonly associated with sleep deprivation.
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