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 C
Explanation
An ankle-foot orthotic can help prevent a plantar flexion contracture of the affected extremity in a client who has right-sided paralysis following a cerebrovascular accident. This device can help maintain the foot and ankle in a neutral position and prevent the development of a contracture.
a. A sequential compression device is used to prevent deep vein thrombosis and is not specifically designed to prevent contractures.
b. An abduction splint is used to maintain the hip in a neutral position and is not specifically designed to prevent contractures of the foot and ankle.
d. A continuous passive motion machine is used to promote joint mobility and is not specifically designed to prevent contractures of the foot and ankle.
Correct Answer is D
Explanation
The client's statement that they will place the suppository as far inside their vagina as they can reach indicates an understanding of the teaching. This ensures that the medication is delivered to the site of infection.
a. The client should continue to use the medication for the full course of treatment, even if their symptoms improve before the treatment is complete.
b. The client can lie on their back or side to insert the suppository; there is no specific requirement to lie on their left side.
c. Lubricant is not typically necessary for the insertion of a vaginal suppository.
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