A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be a priority for this client?
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: Postoperatively, the patient is assessed for complications such as altered respiratory status, wound infection, and hemorrhage. All of the assessments above are part of the plan of care for a client who had had a radical neck dissection but are not the nurse's chief priority.
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The nurse is providing postsurgical care for a 14-month-old girl following a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home
How should the nurse respond? A) "I will help you become very comfortable providing your daughter's care." B) "You must learn how to care for your daughter at home." C) "You will need to learn to collaborate with all the caregivers." D) "There is a lot to learn, and you need a positive attitude."
In caring for a patient just admitted with a pelvic fracture, the assessment that would cause the most concern is:
1. a pain level rating of 8 on a 1 to 10 scale. 2. no urinary output for 8 hours. 3. evidence of bruising along the patient's hips and buttocks. 4. complaints of need for back care from resting in bed.
Taste and smell are closely related.
Answer the following statement true (T) or false (F)
The client had the right trigeminal nerve (all branches) dissected 1 day ago during microvas-cular surgery. When the client is asked to wrinkle his forehead, only the left side wrinkles. What is the nurse's best action?
A. Place the client in a high Fowler's position. B. Document the finding as the only action. C. Assess the corneal reflex. D. Notify the physician.