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.

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Correct Answer is B

Explanation

This question is more focused and directly addresses the reason for the client's current admission. It prompts the client to discuss their chief complaint or presenting symptoms, which is essential information for the nurse to gather during the health history interview.
A. This question is too broad and may overwhelm the client, especially during the initial stages of the health history interview.
C. While discussing the client's feelings about hospitalization is important for providing emotional support and understanding their perspective, this question may not directly promote the discussion of health history data.
D. This question invites the client to share their perspective and provides an opportunity for them to express any immediate health issues or worries they may have. However, it is too broad.

A. The client explains they are not planning to leave their home. B. The client thinks their home will be safer now that there is a baby in the house C. The client thanks the nurse for the information. D. The client puts the number of the crisis center into their phone.

Correct Answer is D

Explanation

It indicates that the client acknowledges the importance of having a safety plan and is willing to take proactive measures to ensure their well-being and that of their child. This response suggests a positive engagement with the safety plan provided by the nurse.
A. This response indicates that the client may not perceive their current situation as unsafe or may not be ready to take action to address potential safety concerns.
B. This response suggests that the client may have misconceptions about how the presence of a baby in the home affects safety, especially in the context of intimate partner violence.
C. While expressing gratitude for the information provided is a positive response, it does not necessarily indicate whether the client understands the seriousness of the situation or plans to utilize the resources provided.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse use to promote this discussion?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

A nurse in a clinic is interviewing a client who will undergo diagnostic testing. The nurse should ask about a client's potential allergies during which phase of the nursing process?

A nurse is planning care for a client who experienced an anaphylactic reaction. Which of the following findings should the nurse identify as the most important indication for a referral to an allergy specialist?

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

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

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?