You are taking care of a client that is recently back from surgery for laryngeal cancer. He has had a total laryngectomy with lymph node removal
a. You are doing family teaching and need to explain the procedure, what was taken out with surgery, what is left, and what the tracheotomy is. How would you do this?
b. What nursing interventions would you expect to include with this surgery?
Students' answers should include the following:
a. Discussion on this should include the age-appropriate language to use. Included in this discussion should be what the surgery was, tissue removed, and the organs left; which are the lungs, bronchi, and trachea. Explaining that the air comes down through the trachea through the bronchi into the lungs should also be part of the explanation. Letting the family know that the client will have a permanent tracheotomy with a stoma and not speak normally ever again will require adjusting as well using an alternative speech method. The emotional and physiologic effect also needs to be addressed.
b. Include in the discussion the head of the bed being elevated and why, deep breathing and coughing and why it is important, the need of oxygen, potential bleeding and suctioning of additional secretions, keeping the airway patent and open, as well as pain control and fluids monitored.
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The nursing student is performing a physical examination on a 6-year-old patient who is being admitted to the pediatric unit with abdominal pain. When would be the most appropriate time in the examination to palpate the patient's abdomen?
a. Palpate tender areas last. b. Palpate tender areas first to get it over. c. Palpate tender areas before inspection. d. Palpate before auscultation.
You are the nurse assessing an 18-year-old woman. You note bruising to the patient's upper arm that appears as fingerprints as well as yellow bruising to the lower eye. The patient makes minimal eye contact during the assessment
How might you best inquire about the bruising? A) "Is anyone physically hurting you?" B) "Tell me about your relationships." C) "Do you want to see a social worker?" D) "Is there something you want to tell me?"
The nurse is providing care to patients for whom she has 24-hour accountability and responsibility. The care delivery system within which the nurse is functioning is most likely:
1. Primary nursing. 2. Case method. 3. Functional nursing. 4. Team nursing.
Which of the following are examples of nursing activities that are considered part of the independent functions of the nursing role? Select all that apply
1. Introduce oneself to the client and interview the client to collect data about physical health status. 2. Talk with the client about his or her abilities to manage personal hygiene activities while in the usual state of health at home. 3. Administer analgesic medication ordered by the health care provider. 4. Incorporate adaptive techniques into nursing care as recommended by occupational therapy. 5. Teach a soon-to-be-discharged client about the medication regimen that the health care provider has prescribed for the client after discharge. Correct