A nurse, during a shift report, learns that a patient under their care is blind. What actions by the nurse would demonstrate effective communication?

Introduce self after entering the patient’s room

Use a firm, loud voice when addressing the patient

Lightly touch the patient’s arm

Provide instructions in clear, simple terms .

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Introducing oneself after entering the patient’s room is a key aspect of effective communication with a blind patient. This helps the patient identify who is in the room with them.
Choice B rationale
Using a firm, loud voice when addressing the patient is not necessarily effective. While it’s important to speak clearly, raising one’s voice can come off as patronizing or disrespectful. It’s better to speak in a normal tone and adjust as needed based on the patient’s feedback.
Choice C rationale

Lightly touching the patient’s arm can be an effective way to gain their attention, especially if they may not have heard you enter the room. However, it’s important to ask for consent before touching the patient.
Choice D rationale
Providing instructions in clear, simple terms can be very helpful for a blind patient. This can help them understand what is happening and what they need to do.

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Correct Answer is A

Explanation

Choice A rationale
In the case of a major ischemic stroke, the medication that a nurse would anticipate the doctor to order is tissue plasminogen activator (tPA)8. This medication works by dissolving the clot that is blocking blood flow to the brain. It is most effective when given as soon as possible after the onset of stroke symptoms.
Choice B rationale

Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used to relieve pain and reduce inflammation. It is not typically used in the treatment of ischemic stroke.
Choice C rationale
Aspirin is an antiplatelet drug that is sometimes used in the prevention of stroke. However, it is not typically used as an immediate treatment for a major ischemic stroke.
Choice D rationale
Warfarin is an anticoagulant medication that is used to prevent blood clots from forming or growing larger. It is not typically used as an immediate treatment for a major ischemic stroke.

A. Have the patient lie flat for 6 hours. B. Have the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees. C. Early ambulation. D. Have the patient lie flat for 1 hour, then sit up for 1 hour before ambulating.

Correct Answer is A

Explanation

Choice A rationale
After a lumbar puncture, it is important for the patient to lie flat for approximately 6 hours. This position helps to prevent headaches that can occur after the procedure, which are caused by leakage of cerebrospinal fluid at the needle puncture site. Lying flat allows the puncture site to seal and prevents the leakage of cerebrospinal fluid.
Choice B rationale
Having the patient lie in a semi-Fowler’s position with the head of the bed at 35 degrees is not typically recommended immediately after a lumbar puncture. This position could potentially increase the risk of a post-lumbar puncture headache.
Choice C rationale
Early ambulation is not recommended after a lumbar puncture. Moving around too soon after the procedure can increase the risk of a headache and may also increase the risk of complications at the puncture site.
Choice D rationale
Having the patient lie flat for 1 hour, then sit up for 1 hour before ambulating is not a typical recommendation after a lumbar puncture. The standard recommendation is to have the patient lie flat for approximately 6 hours to reduce the risk of complications.

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A nurse, during a shift report, learns that a patient under their care is blind. What actions by the nurse would demonstrate effective communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a 46-year-old patient who has had a major ischemic stroke in the last 25 minutes. The patient’s vital signs are: Temp 98.7, HR: 98, RR: 28, BP: 165/98. Which medication does the nurse anticipate the doctor will order?

Correct Answer is A

Explanation

A patient is having 20 mL of cerebral spinal fluid removed via a lumbar puncture. What intervention is important after the procedure?

Correct Answer is A

Explanation

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