A nurse is caring for a client who is postoperative.
Vital Signs.
0800: Nurses' Notes.
BP 118/72 mm Hg. Heart rate 82/min.
Respiratory rate 16/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
1000: BP 128/82 mm Hg. Heart rate 94/min.
Respiratory rate 18/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
Vital Signs.
Nurses' Notes.
0745: Client awake and eating breakfast while watching the news on television.
Client has hearing loss, does not wear a 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: Nurses' Notes.
Client ambulated in the hallway with a physical therapist.
Client grimacing, appears upset, and is guarding incisional site.
Reports pain as 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.
1300: Ate 75% of lunch.
Several visitors at the bedside.
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.
Correct Answer : A,B,C,E,F
The correct answers are a. Client's hearing deficit, b. Volume of the client's television, c. Numerous visitors in the client's room, e. Adverse effects of opioid analgesic, and f. Using earphones while listening to music.
Choice A rationale: A client with hearing loss who does not wear a hearing aid may experience difficulty understanding spoken communication, especially in noisy environments, leading to potential miscommunication or misunderstanding.
Choice B rationale: Loud television volume can make it difficult for both the nurse and the client to hear each other, causing interference in their communication and potentially leading to errors in information exchange.
Choice C rationale: The presence of numerous visitors in the room can cause distractions, background noise, and overall interference with the nurse-client communication process, potentially affecting the quality and accuracy of the information exchanged.
Choice E rationale: Opioid analgesics can cause adverse effects such as drowsiness, confusion, or cognitive impairment, hindering effective communication between the nurse and the client, as the client's ability to comprehend, retain, and convey information may be impaired.
Choice F rationale: The use of earphones while listening to music can impair the client's ability to hear the nurse, creating a barrier to effective communication. This could potentially lead to missed or misunderstood information and, consequently, affect the quality of care.
Choice D rationale (Incorrect choice): While an increase in pain after ambulation could affect the client's mood, cooperation, and ability to engage in effective communication, it does not directly create a barrier to the nurse's ability to communicate with the client. Pain management is an essential aspect of postoperative care, and effective communication can actually facilitate pain assessment, management, and overall client well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Guiding the client away from background noise is a helpful suggestion for a client with hearing loss, but in the context of reviewing discharge instructions, it may not be sufficient. The primary issue is not background noise but the ability of the client to hear and understand the nurse's instructions.
Choice B rationale:
Providing a copy of the instructions printed in Braille is not appropriate for a client with hearing loss. Braille is a tactile reading and writing system for people who are blind or visually impaired. It does not address the client's hearing loss.
Choice C rationale:
Standing next to the client when speaking is the most appropriate action for a nurse when reviewing discharge instructions with a client who has hearing loss. This allows the client to see the nurse's facial expressions, lip movements, and gestures, which can aid in understanding. It also minimizes the distance between the nurse's mouth and the client's ears, making it easier for the client to hear.
Choice D rationale:
While repeating phrases that the client misunderstands is a helpful communication strategy, it should be used in conjunction with standing close to the client, not as the sole method. Standing close and speaking clearly should be the primary approach to facilitate effective communication with a client who has hearing loss.
Correct Answer is B
Explanation
Choice A rationale:
Health education involves providing information and knowledge to clients about their health, which is essential but doesn't directly relate to the nurse's action of blood pressure screening. This choice is less appropriate in this context.
Choice B rationale:
Health promotion encompasses actions that aim to enhance an individual's well-being and prevent illness. Blood pressure screening is a preventive measure to identify individuals at risk of hypertension, making it a key component of health promotion. The nurse is contributing to the client's overall health by identifying potential hypertension issues.
Choice C rationale:
Holistic health refers to a broader approach to healthcare that considers the physical, mental, and social aspects of an individual. While it's essential, the nurse's specific action of blood pressure screening doesn't necessarily encompass all these aspects. It's more focused on identifying a specific health condition.
Choice D rationale:
Disease prevention involves activities to prevent the occurrence or progression of diseases. Blood pressure screening falls under this category as it aims to prevent complications related to hypertension, making this choice a relevant consideration. However, "Health promotion" is a more precise and comprehensive description of the nurse's role in this scenario.
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