Author Question: A client who has to undergo a thyroidectomy is worried that he may have to wear a scarf around his ... (Read 42 times)

ereecah · **on:** Jul 22, 2018

A client who has to undergo a thyroidectomy is worried that he may have to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?

A) Risk for impaired physical mobility due to surgery
B) Ineffective denial related to poor coping mechanisms
C) Disturbed body image related to the incision scar
D) Risk of injury related to surgical outcomes

Question 2

A newly graduated nurse has been assigned to work with one assistive personnel staff member. When delegating skills, which guidelines should the nurse use? (Select all that apply.)

a. Assign just bed making skills and feeding tasks.
b. Assess the knowledge of the assistive personnel.
c. Match tasks to the assistant's skills.
d. Have the nursing assistant document as-sessment findings.
e. Assess skill levels of assistive personnel.

voltaire123 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Feedback:
The client is concerned about the surgery scar on his neck, which would disturb his body image; therefore, the appropriate diagnosis should be disturbed body image related to the incision scar. Risk for impaired physical mobility may be present after surgery, but is not related to the concerns expressed by the client. Likewise, ineffective denial related to poor coping mechanisms and injury related to surgical outcomes are also not related to the client's concern.

Answer to Question 2

B, C, E
The guidelines for delegation include the following: assess the knowledge and skills of the per-son to whom you are delegating; match tasks to the assistant's skills; and provide feedback. It is the nurse's responsibility, not the assistant's, to complete documentation of assessment findings. The nurse can assign/delegate more than just bed making skills and feeding tasks.