A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Sit beside the client.

Speak slowly and loudly to the client.

Dim the lights in the client's room.

Choose a private room for the interview.

Answer and Explanation

The Correct Answer is D

The correct answer is choice D: Choose a private room for the interview.

Choice D rationale:

Opting for a private room for the interview is essential when interacting with a client who uses a hearing aid. This choice helps minimize background noise and distractions, ensuring effective communication between the nurse and the client. Adequate lighting and minimizing auditory interference are crucial for clients with hearing difficulties.

Choice A rationale:

Sitting beside the client is a considerate approach, but it may not directly address the hearing aid user's needs. The focus should be on creating an optimal environment for communication, which includes minimizing auditory and visual obstacles.

Choice B rationale:

Speaking slowly and loudly to the client is not the most appropriate approach. While speaking clearly and facing the client is recommended, speaking loudly may distort sounds and hinder understanding for clients with hearing aids.

Choice C rationale:

Dimming the lights in the client's room is not necessary for addressing the needs of a client with a hearing aid. Adequate lighting is important for lip-reading and effective communication, especially for clients who rely on visual cues.

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Correct Answer is D

Explanation

The correct answer is choice d. Actual loss.

Choice A rationale: Complicated grief refers to an intense and prolonged period of mourning that interferes with daily life. It is not typically associated with the immediate postoperative period following a mastectomy.

Choice B rationale: Maturational loss is related to the normal life transitions and developmental changes, such as children leaving home or retirement. It does not apply to the loss experienced after a mastectomy.

Choice C rationale: Disenfranchised grief occurs when a person’s grief is not socially recognized or supported, such as the loss of a pet or an ex-spouse. While the grief after a mastectomy can be profound, it is generally acknowledged and supported by healthcare providers and society.

Choice D rationale: Actual loss refers to the tangible loss of a person, object, or body part. In this case, the client is experiencing the loss of a breast, which is a significant and visible change to their body. This type of loss can deeply affect a person’s self-image and emotional well-being.

A. Client is itching from medication. B. Client states, "I started to itch after taking that medication.". C. It appears that the client has a rash from the medication. D. Rash from medication noted.

Correct Answer is B

Explanation

The correct answer is choice B. Client states, "I started to itch after taking that medication."

Choice A rationale:

"Client is itching from medication." This statement is not a comprehensive description of the situation and lacks specific information. It doesn't provide any context about when the itching occurred or the client's own observation.

Choice B rationale:

"Client states, 'I started to itch after taking that medication.'" This choice is the correct answer because it accurately documents the client's own statement about the itching and the timing in relation to taking the medication. It includes a direct quote, which helps in maintaining accurate and patient-centered documentation.

Choice C rationale:

"It appears that the client has a rash from the medication." This statement includes an assumption and subjective language ("It appears"), which can be misleading in documentation. It's essential to provide factual and objective information in medical records.

Choice D rationale:

"Rash from medication noted." This choice lacks detail and doesn't capture the client's perspective or the timing of the symptom. It's important to include the client's statement and the time frame in which the symptom occurred.

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A nurse in a long-term care facility is collecting admission data from a client who uses a hearing aid. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a mastectomy. The client states, "I can barely look at myself in the mirror." The nurse should identify that the client is experiencing which of the following?

Correct Answer is D

Explanation

A nurse is caring for a client who reports itching 30 min after receiving a newly prescribed medication. Which of the following data should the nurse document in the client's medical record?

Correct Answer is B

Explanation

A nurse is collecting data from a client following a lumbar puncture. The nurse should identify which of the following findings as a potential adverse effect of this procedure?

A nurse is assisting with the admission of an older adult client to an acute care facility. The client states that they are afraid to go to sleep, fearing they will not wake up. Which of the following is a therapeutic response the nurse should make?

A nurse is caring for a client who has been vomiting and has diarrhea. Which of the following findings should the nurse identify as an indication of fluid volume deficit?

A nurse and an assistive personnel (AP) are providing postmortem care for a deceased client before visitation by the family. Which of the following actions by the AP requires intervention by the nurse?

A nurse is reinforcing teaching with the partner of a client who is immobile. Which of the following instructions should the nurse give the partner about turning the client in bed?

A nurse is preparing to remove staples from a client's incision. Which of the following actions should the nurse take?

A nurse in an acute care setting is documenting postmortem care in a client's medical record. Which of the following information should the nurse include in the documentation?

A nurse is assisting with the admission of a client to a medical-surgical unit. Which of the following findings should the nurse identify as an indication that the client is malnourished?