Nokea
A home care nurse is visiting an older adult with long-standing diabetes who reports pain and numbness in their feet. What education is most appropriate for this patient?
- A. Take acetaminophen or over-the-counter analgesic when pain occurs.
- B. Increase intake of foods containing vitamins B6, B12, and folate.
- C. Explain that phantom limb pain can become chronic, but psychosocial support can help.
- D. Validate the patient's understanding of foot care for patients with diabetes.
Correct Answer: D
Rationale: Patients with diabetes can develop peripheral neuropathy resulting in loss of sensation and reduced blood flow. The loss of sensation can promote injury the patient does not readily notice. Therefore, those with diabetes must perform special foot care and visual inspection.
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A nurse is caring for a patient with a severe hearing deficit who reads lips and uses sign language. Which nursing intervention would best prevent sensory alterations for this patient?
- A. Turning the radio or television volume up very loud and closing the door to his room
- B. Preventing embarrassment and emotional discomfort as much as possible
- C. Providing daily opportunities for them to participate in a social hour with six to eight people
- D. Encouraging daily participation in exercise and physical activity
Correct Answer: C
Rationale: Providing opportunities for the patient to socialize builds on their strength of being able to lip-read and helps prevent sensory deprivation from hearing loss.
A nurse is caring for an older adult who has a severe visual deficit related to glaucoma. Which nursing action is most appropriate when providing care for this patient?
- A. Assisting the patient to ambulate by walking slightly behind them and grasping the arm
- B. Concentrating on the patient's sense of sight and limit diversions that involve other senses
- C. Staying outside of the patient's field of vision when performing personal hygiene for them
- D. Cueing the patient when the conversation has ended and when leaving the room
Correct Answer: D
Rationale: When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when they are leaving the room to prevent confusion and promote safety.
A visiting nurse conducts a visit for an 11-month-old infant. The nurse finds the infant lying on the floor, rocking back and forth with a flat expression, and few vocalizations. Which nursing action would be appropriate at this time?
- A. Assessing the type of stimulation the infant has been receiving
- B. Removing the infant from the grandmother's care as the child has not progressed.
- C. Explaining that their negligence has resulted in the child's speech delays
- D. Taking no action, as this is expected behavior for an 11-month-old infant
Correct Answer: A
Rationale: Using the first step of the nursing process, assessment, the nurse determines if the types of stimulation given by the infant's parents validate that they understand the education provided at the parenting classes. The grandmother's reduced vision would not impact the child's speech. While the infant's development is not progressing, accusing the parents of negligence is premature.
In a group home where most residents have varying degrees of visual or hearing impairments and some are periodically confused, what nursing action is essential?
- A. Maintaining safety and preventing sensory deterioration
- B. Insisting that residents participate in as many self-care activities as possible
- C. Emphasizing and reinforcing individual patient strengths
- D. Encouraging reminiscence and life review in groups
Correct Answer: A
Rationale: Safety is a basic physiologic need that must be met before higher-level needs such as love and belonging, self-esteem, and self-actualization can be met.
A nurse is assessing a patient for gustatory disturbances. Which question asked by the nurse would be appropriate for this assessment?
- A. "Have you been experiencing any loss of taste or strange tastes lately?"
- B. "Have you smelled odors lately that others cannot smell?"
- C. "Can you tell me what object I am placing in your hand right now?"
- D. "Have you found it difficult to communicate verbally?"
Correct Answer: A
Rationale: When the nurse asks: "Have you been experiencing any strange tastes lately?" the nurse is assessing for gustatory disturbances. The question: "Have you smelled odors lately that others cannot smell?" assesses for olfactory disturbances. When the nurse asks: "Can you tell me what I am placing in your hand right now?" the nurse is assessing for tactile disturbances. The question "Have you found it difficult to communicate verbally?" assesses for transmission-perception-reaction.