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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly and waxy borders. It is the most common type of skin cancer and typically occurs in areas exposed to the sun.
Choice A rationale
Actinic keratosis is a precancerous condition that appears as rough, scaly patches on sun-exposed skin.
Choice B rationale
Malignant melanoma is a more aggressive form of skin cancer that often appears as a new, unusual growth or a change in an existing mole.
Choice C rationale
Squamous cell carcinoma typically appears as a firm, red nodule or a flat lesion with a scaly, crusted surface. .
Correct Answer is D
Explanation
Choice A rationale
Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.
Choice B rationale
Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.
Choice C rationale
Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.
Choice D rationale
Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.
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