A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?
State the options loudly in a high-pitched voice.
Ask the client's partner to choose their meal.
Expect extended time for verbal responses.
Ask the client to point to items on a picture menu.
The Correct Answer is D
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.
B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.
C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.
D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.
Correct Answer is D
Explanation
A. Attach the client's NG tube to low intermittent suction: Suction may be used after lavage for decompression, but during lavage, the focus is on instilling and withdrawing solution manually to clear the stomach of blood or contents.
B. Instill the lavage solution into the client's NG tube in volumes of 500 mL at a time: This volume is excessive and could increase the risk of aspiration or discomfort. Typically, 100–200 mL is used per instillation.
C. Instill chilled lavage solution into the client's NG tube: Chilled solutions are not recommended as they may induce hypothermia and have not been shown to effectively control bleeding. Room-temperature solution is preferred.
D. Use 0.9% sodium chloride for irrigation of the NG tube: Isotonic saline is the recommended solution for gastric lavage, as it helps prevent electrolyte imbalance and irritation.
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