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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Resting in bed for at least 2 days is not necessary after cataract surgery. The client should resume normal activities as soon as possible, but avoid strenuous activities that increase intraocular pressure.

Choice B reason: Deep breathing and coughing four times a day are not related to cataract surgery. This is a technique to prevent respiratory complications after abdominal or thoracic surgery.

Choice C reason: After two days, a creamy discharge is not normal. This could indicate an infection or inflammation of the eye. The client should report any changes in vision, pain, redness, swelling, or discharge to the provider.

Choice D reason: Keeping the head up and straight is the correct instruction. This helps to prevent increased intraocular pressure and bleeding in the eye. The client should also avoid rubbing or touching the eye, wearing sunglasses to protect from bright light, and using prescribed eye drops as directed.

A. Seasonal allergies B. History of GERD C. Benzodiazepines D. Completed antibiotics 10 days ago

Correct Answer is C

Explanation

Choice A Reason: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing.

Choice B Reason: History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing.

Choice C Reason: Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions.

Choice D Reason: Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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