A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Stand directly in front of the client.
Rephrase statements the client does not hear.
Speak using his usual tone of voice.
Determine if the client uses hearing aids.
The Correct Answer is D
Choice A Reason: This is incorrect because standing directly in front of the client is not the priority action by the nurse when admitting a client who has a partial hearing loss. Standing directly in front of the client can enhance communication, but it is not as important as assessing the client's hearing status and needs.
Choice B Reason: This is incorrect because rephrasing statements the client does not hear is not the priority action by the nurse when admitting a client who has a partial hearing loss. Rephrasing statements can improve understanding, but it is not as essential as evaluating the client's hearing level and preferences.
Choice C Reason: This is incorrect because speaking using his usual tone of voice is not the priority action by the nurse when admitting a client who has a partial hearing loss. Speaking using his usual tone of voice may or may not be appropriate, depending on the client's hearing ability and comfort. The nurse should adjust his tone of voice based on the client's feedback and response.
Choice D Reason: This is the correct choice because determining if the client uses hearing aids is the priority action by the nurse when admitting a client who has a partial hearing loss. Hearing aids are devices that amplify sound and improve hearing for people with hearing loss. The nurse should determine if the client uses hearing aids, and if so, check their function, fit, and battery life. The nurse should also ask about any other assistive devices or strategies that the client uses to communicate effectively.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.
Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.
Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.
Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because both ulcerative colitis and Crohn's disease are inflammatory bowel diseases (IBD) that cause chronic inflammation of the digestive tract. The inflammation can cause symptoms such as abdominal pain, diarrhea, bleeding, weight loss, or fever. The nurse should educate the client on how to manage inflammation and prevent complications.
Choice B reason: This is incorrect because both ulcerative colitis and Crohn's disease do not affect the entire alimentary canal, but different parts of it. Ulcerative colitis affects only the colon (large intestine) and rectum, while Crohn's disease can affect any part of the digestive tract from mouth to anus, most commonly the ileum (the last part of the small intestine). The nurse should explain the differences in location and extent of
the diseases.
Choice C reason: This is incorrect because both ulcerative colitis and Crohn's disease do not always require a bowel diversion, but only in some cases. A bowel diversion is a surgical procedure that creates an opening (stoma) in the abdomen to divert fecal matter into an external bag or pouch. It may be done to treat severe complications such as perforation, obstruction, fistula, or cancer. The nurse should inform the client about the indications, types, and care of bowel diversions.
Choice D reason: This is incorrect because both ulcerative colitis and Crohn's disease are not caused by low-fat, high-fiber diets, but by unknown factors. The exact causes of IBD are not clear, but they may involve genetic, immune, environmental, or microbial factors. Low-fat, high-fiber diets may help prevent or reduce symptoms of IBD, but they do not cause them. The nurse should advise the client on how to follow a balanced and nutritious diet that suits their individual needs and preferences.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today