Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

"I have cared for patients who were able to have the tracheostomy reversed."

“I understand that you might be apprehensive."

“I will be efficient and give care quickly."

"I will wait until your tracheostomy heals before teaching."

Answer and Explanation

The Correct Answer is B

A. "I have cared for patients who were able to have the tracheostomy reversed. While this may offer hope, it shifts the focus to long-term outcomes rather than addressing the patient's current emotional state. Not all tracheostomies are reversible, and offering this reassurance prematurely may set unrealistic expectations.

B. “I understand that you might be apprehensive." This statement acknowledges the patient's anxiety and fosters trust. Demonstrating empathy helps reduce emotional distress, encourages open communication, and supports emotional adaptation to the tracheostomy.

C. “I will be efficient and give care quickly." Although efficiency is important, this response may come off as dismissive of the patient's emotional needs. It prioritizes task completion over patient-centered care and fails to address the underlying anxiety.

D. "I will wait until your tracheostomy heals before teaching." Teaching should begin early, even in small steps, to help the patient gradually understand and adapt to tracheostomy care. Delaying education may increase fear, uncertainty, and dependence on others for care.

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Correct Answer is A

Explanation

A. A possible airway obstruction: The tripod positionis a classic sign of epiglottitis and indicates the child is attempting to maximize airway patency. This posture helps keep the airway open and suggests significant upper airway obstruction, requiring immediate intervention.

B. The presence of pain: While children with epiglottitis often experience throat pain, this posture is not primarily used to relieve pain. It is associated with efforts to ease breathing and maintain airflow in the face of an obstructed or narrowed airway.

C. Extreme fatigue: Fatigue may occur in respiratory illnesses, but the tripod position is an active posture that requires muscle engagement. It is not a typical sign of fatigue and more accurately reflects respiratory distress and airway compromise.

D. Dehydration: Dehydration may be present in epiglottitis due to poor oral intake, but it does not cause the child to assume the tripod position. The posture is a compensatory mechanism for airway obstruction, not a direct result of fluid imbalance.

A. Assess the posterior pharynx for active bleeding. B. Place the client in the side lying position. C. Give the client juice through a straw. D. Offer the client ice cream to coat the throat.

Correct Answer is A

Explanation

A. Assess the posterior pharynx for active bleeding:Frequent throat clearing without reported pain after a tonsillectomy may indicate active bleeding, which can be life-threatening. Silent bleeding may drip down the throat and trigger subtle clearing rather than coughing or spitting, making visual inspection an immediate priority.

B. Place the client in the side lying position:Side-lying can help prevent aspiration if bleeding occurs, but it does not replace the need to directly assess for bleeding first. Positioning should follow an initial airway and bleeding assessment.

C. Give the client juice through a straw:Using a straw is discouraged after tonsillectomy because the suction motion can disrupt clots and provoke bleeding. Juice may be appropriate for hydration, but not with a straw and not before checking for bleeding.

D. Offer the client ice cream to coat the throat:Cold soft foods like ice cream may soothe the throat and reduce swelling, but this should not be the first action when silent bleeding is suspected. The priority is ensuring that no active bleeding is occurring before offering food.

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Which statement is most important for the nurse to make when caring for an anxious patient with a new tracheostomy?

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