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 C rationale:
Respite care provides support for a client's caregiver. Respite care offers temporary relief or rest for caregivers who are taking care of individuals with chronic illness, disabilities, or those approaching the end of life. It allows caregivers to have a break from their responsibilities, reducing caregiver burnout and stress. This type of support helps maintain the caregiver's physical and emotional well-being, which, in turn, benefits the client's overall care.
Choice A rationale:
Postmortem care is the care provided to a deceased client, and it does not directly support the caregiver of a living client. It is essential for ensuring respectful and appropriate handling of the deceased individual but does not provide support to caregivers.
Choice B rationale:
Home care involves healthcare services delivered in the client's home, which can be beneficial for the client's care but does not specifically address the needs of the caregiver. While it may indirectly ease the caregiver's responsibilities, it is not a service designed to support caregivers directly.
Choice D rationale:
Restorative care focuses on rehabilitation and restoring the client's health and independence, which primarily benefits the client rather than the caregiver. It is not a service aimed at supporting caregivers in the same way that respite care does.
Correct Answer is D
Explanation
Choice A rationale:
Standards of care for monitoring clients with a history of blood pressure elevation are important, but they are not the best resource for health promotion activities for clients with hypertension. This choice is more focused on monitoring and care standards.
Choice B rationale:
A critical pathway for clients who have had a stroke is specific to a different condition and not related to health promotion for clients with hypertension. It does not provide the information needed for the presentation.
Choice C rationale:
Acute care facility protocol for clients experiencing a hypertensive crisis is important for managing emergencies, but it is not the best resource for health promotion activities. It deals with crisis management rather than prevention.
Choice D rationale:
Clinical practice guidelines for the management of high blood pressure are the most appropriate resource for the nurse's presentation on health promotion activities for clients with hypertension. These guidelines provide evidence-based recommendations for managing and preventing high blood pressure, making them the best choice for the presentation. .
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.