A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?

Rephrase statements the client does not hear.

Determine if the client uses hearing aids.

Speak using his usual tone of voice and directly in front of the client.

Use hand gestures to communicate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.

Choice B rationale

Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.

Choice C rationale

Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.

Choice D rationale

Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.

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Correct Answer is D

Explanation

Choice A rationale

Allowing the client to ambulate one day after a detached retinal repair is not recommended. Ambulation can increase intraocular pressure and disrupt the healing process of the retina. The client should be advised to limit physical activity to prevent any strain on the eye.

Choice B rationale

Removing the eye patch during the day is not advisable as it can expose the eye to potential injury or infection. The eye patch helps protect the eye and maintain the correct position for healing. It should be worn as directed by the healthcare provider.

Choice C rationale

Encouraging coughing and deep-breathing exercises is not appropriate for a client who has undergone retinal repair. These activities can increase intraocular pressure and risk detachment of the retina. The client should avoid activities that cause strain or pressure on the eyes.

Choice D rationale

Avoiding reading and writing is crucial for a client one day postoperative following a detached retinal repair. These activities can cause rapid eye movements and strain, which can interfere with the healing process and reattachment of the retina. The client should be advised to rest their eyes and avoid any activities that require intense focus or eye movement.

A. Headaches and blurred vision. B. Tremors and weakness. C. Rash symptoms. D. Painful joints.

Correct Answer is C

Explanation

Choice A rationale

Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.

Choice B rationale

Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.

Choice C rationale

Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.

Choice D rationale

Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.

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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client 1 day postoperative following a detached retinal repair. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

A client calls the health care clinic and asks the nurse to describe the first signs of Lyme disease. The nurse informs the client to watch for which signs/symptoms of stage I Lyme disease?

Correct Answer is C

Explanation

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A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?