A nurse is caring for a client who is postoperative. Nurses' Notes

0745:

Client awake and eating breakfast while watching the news on television. Client has hearing loss, does not wear hearing aid, and TV volume is loud. Rates pain as a 2 on a 0 to 10 pain scale.

Incisional dressing dry and intact. 1000:

Client ambulated in hallway with physical therapist. Client grimacing. appears upset and is guarding incisional site. Reports pain a 5 on a 0 to 10 pain scale. Opioid analgesic administered.

1045

Client resting with eyes closed and listening to music with earphones. Reports feeling "very sleepy after pain medication. Now rates pain as a 3 on a 0 to 10 pain scale.
Which of the following factors could present a barrier to the nurse effectively communicating with the client? (Select all that apply).

Client's hearing deficit

Volume of the client's television

Numerous visitors in the client's room

Increase in pain after ambulation

Adverse effects of opioid analgesic

Using earphones while listening to music

Answer and Explanation

Correct Answer : A,C,D,E,F

The client's hearing deficit can certainly present a barrier to effective communication, as it may affect their ability to hear and understand verbal instructions or information provided by the nurse.
B.   The loud volume of the client's television is not a barrier in this case as the client has hearing loss.
C.   Having numerous visitors in the client's room can create distractions and make it challenging for the nurse to engage in private, focused communication with the client.
D.   An increase in pain after ambulation can impact the client's ability to focus and engage in effective communication. The client may be preoccupied with managing their pain, which can hinder their receptiveness to communication from the nurse.
E.   Adverse effects of opioid analgesic: Adverse effects of opioid analgesics, such as drowsiness or sedation, can impair the client's cognitive function and alertness, making it difficult for them to participate actively in communication with the nurse.
F.   Using earphones while listening to music may create a physical barrier to communication, as it limits the nurse's ability to speak directly to the client or gain their attention.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

This is important because it allows the nurse to assess the client's ability to communicate in their primary language. Knowing the client's level of fluency helps the nurse determine the most effective communication strategies and whether an interpreter is necessary.

B. While nodding can be a form of nonverbal communication indicating understanding, relying solely on this may not accurately gauge the client's comprehension.

C. Even in the presence of n interpreter, the nurse should speak directly to the client.

D. Family members may not be proficient in both languages or may not accurately convey medical information.

A. Support client-requested rituals. B. Encourage family to be present for MANH. C. Following withdrawal of MANH, offer mouth sponges with preferred flavors as needed. D. Request spiritual advisor visit, if applicable E. Following withdrawal of MANH, suction oral cavity for pooling of secretions as needed F. Educate client on the steps of the dying process

Correct Answer is ["A","B","C","D","E"]

Explanation

Supporting the client's rituals can provide comfort and dignity during this challenging time. It honors their preferences and cultural or religious beliefs, contributing to their overall well-being.

Having loved ones present can offer emotional support to both the client and their family members during the withdrawal of MANH. It allows for meaningful connections and facilitates closure.

Providing mouth sponges with preferred flavors can help alleviate dryness and discomfort in the oral cavity that may occur after the withdrawal of MANH. It promotes comfort and enhances the client's quality of life.

Spiritual support can be valuable for clients and their families during the end-of-life process. If the client desires spiritual guidance or support, arranging for a visit from a spiritual advisor can address their spiritual needs and provide comfort.

Suctioning the oral cavity for pooling secretions can help maintain the client's comfort and prevent aspiration, particularly if the client is unable to swallow effectively. It supports respiratory hygiene and comfort.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

Correct Answer is ["A","B","C","D","E"]

Explanation

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

The nurse is completing an assessment of a client who was sexually assaulted. What assessment should the nurse conduct last?

A nurse manager in a community clinic is planning an in-service to increase staff nurses' knowledge on cultural diversity in health care. Which of the following information should the nurse manager include in the presentation? (Select All that Apply)

A nurse has just finished a wound irrigation for a client who requires contact precautions. Which of the following pieces of personal protective equipment (PPE) should the nurse remove first?

A nurse manager in a community clinic is explaining the concept of culture to a newly licensed nurse. Which of the following statements should the nurse manager use to describe a subculture?

A nurse is precepting a student nurse interviewing a client with a different cultural background. Which nonverbal behavior by the student indicates that the nurse should intervene? (Select all that apply)