A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?
Increase her voice when speaking to the client
Lower the bed rails before lowering the bed
Use hand gestures to point to where the client will walk
Stand slightly in front and to one side of the client
The Correct Answer is D
Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: Sweating and pallor are early signs and symptoms of dumping syndrome, which is a condition where food moves too quickly from the stomach to the small intestine, causing rapid fluid shifts and hormonal changes. Sweating and pallor are caused by hypoglycemia, which occurs when the high concentration of food in the small intestine stimulates insulin secretion.
Choice B Reason: Abdominal cramping and pain are late signs and symptoms of dumping syndrome, which occur about one to three hours after eating. Abdominal cramping and pain are caused by intestinal distension, spasms, and gas formation.
Choice C Reason: Double vision and chest pain are not signs and symptoms of dumping syndrome, but may indicate other serious conditions, such as stroke or heart attack. Double vision and chest pain should be reported to the provider immediately.
Choice D Reason: Bradycardia and indigestion are not signs and symptoms of dumping syndrome, but may be related to other gastrointestinal disorders, such as gastritis or peptic ulcer disease. Bradycardia and indigestion should be evaluated by the provider for further diagnosis and treatment.
Correct Answer is D
Explanation
Choice A Reason: Decreased thickness of tympanic membranes is not a physiological change to hearing in older adult clients. The tympanic membranes are thin and flexible structures that vibrate in response to sound waves. The thickness of the tympanic membranes does not change significantly with age.
Choice B Reason: Decreased tinnitus is not a physiological change to hearing in older adult clients. Tinnitus is a ringing or buzzing sound in the ears that may be caused by various factors, such as noise exposure, ear infections, medications, or aging. Tinnitus may increase or decrease with age, depending on the underlying cause.
Choice C Reason: Decreased ear wax is not a physiological change to hearing in older adult clients. Ear wax is a natural substance that lubricates and protects the ear canal from dust, bacteria, and insects. Ear wax production may vary with age, but it does not affect hearing unless it accumulates and blocks the ear canal.
Choice D Reason: Decreased ability to hear high-frequency sounds is a physiological change to hearing in older adult clients. This is also known as presbycusis, which is a gradual loss of hearing that occurs as part of aging. Presbycusis affects the ability to hear high-pitched sounds, such as consonants, birdsong, or alarms.
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