The nurse is caring for a patient who had a radical neck dissection for treatment of a malignant tumor. Which of the following nursing assessments would be a priority for this patient?
A) Presence of acute pain and anxiety
B) Tissue integrity and color of the operative site
C) Respiratory status and airway clearance
D) Self-esteem and body image
Ans: C
Feedback: All of the assessments above are part of the plan of care for a patient who has had a radical neck dissection but are not the nurse's chief priority. Assessment of respirations, a vital function, is the most important. It is crucial for the nurse to establish that the patient's breathing is within normal limits and that he is not experiencing initial symptoms of aspiration pneumonia due to inability to manage oral secretions.
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A) A special body of knowledge enhanced through scientific research. B) Unique clothing that identifies the practitioner. C) A code of ethics that guides decision making. D) Practitioners educated in colleges and universities.
The nurse refers a post-op mastectomy client to Reach to Recovery based on the understanding that the group's primary purpose is to:
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The licensed practical/vocational nurse (LP/VN) is caring for a client who is frequently admitted to the hospital with chronic renal failure
In the past, the client wanted his family and neighbors to visit freely and welcomed the nursing staff to share information about the client's health. The LP/VN is approached by the client's neighbor in the lobby of the hospital asking, "Could you tell me where Mary Smith is and what is going on with her?" Which is the best response to make to the client's neighbor? A) "Let me check to see what room your neighbor is in and her visitor status." B) "Oh, sure I am caring for her; she is in room 1203." C) "You will need to check with Mary's family; she is not on my unit." D) "She is in room 1203, and she is having problems with her dialysis access."