Nokea
The nurse is developing a care plan for a client with a hearing impairment. Which of the following interventions should the nurse take? Select all that apply.
- A. Ensure that the room is well lit when communicating with the client.
- B. Use non-verbal forms of communication like gestures and sign language, if applicable.
- C. Speak loudly and shout when communicating with the client.
- D. Face the client directly when speaking.
- E. Provide written information as needed.
Correct Answer: A,B,D,E
Rationale: For hearing impairment, a well-lit room aids lip-reading, non-verbal communication and facing the client directly improve understanding, and written information supports communication. Shouting can distort speech and is not effective.
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The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses and treats bleeding, blood products (C) correct hypovolemia, and a Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention.
The client tells the nurse that since his diagnosis of stomach cancer, he has been having trouble sleeping and is frequently preoccupied with thoughts about how his life will change. He says, 'I wish my life could stay the same.' Based on this information, which one of the following nursing diagnoses would be appropriate at this time?
- A. Ineffective coping related to the diagnosis of cancer.
- B. Insomnia related to fear of the unknown.
- C. Grieving related to the diagnosis of cancer.
- D. Anxiety related to the need for gastric surgery.
Correct Answer: C
Rationale: The client's statement and symptoms suggest grieving related to the life-altering diagnosis of stomach cancer. This diagnosis best captures the emotional response to the anticipated changes.
The client with a hearing aid does not seem to be able to hear the nurse. The nurse should do which of the following?
- A. Contact the client's audiologist.
- B. Cleanse the hearing aid ear mold in normal saline.
- C. Irrigate the ear canal.
- D. Check the hearing aid's placement.
Correct Answer: D
Rationale: Checking the hearing aid's placement is the first step, as improper placement or a low battery is a common cause of ineffective hearing aid function.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- A. Tell the client it is impossible to feel the pain.
- B. Show the client that the toes are not there.
- C. Explain to the client that her pain is real.
- D. Give the client the prescribed opioid analgesic.
Correct Answer: C
Rationale: Phantom limb pain is real and distressing; acknowledging it validates the client's experience.
A client tells the nurse his vision is blurred and hazy throughout the entire day. The nurse should recommend that the client do which of the following?
- A. Purchase a pair of magnifying glasses.
- B. Wear glasses with tinted lenses.
- C. Schedule an appointment with an optician.
- D. Schedule an appointment with an ophthalmologist.
Correct Answer: D
Rationale: An ophthalmologist is a physician who specializes in the treatment of disorders of the eye, and the nurse should advise the client to see a physician. An optician makes glasses, and it is not known at this point what the best treatment for the client is. Magnifying glasses or tinted lenses do not correct hazy or blurred vision.