A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?
Limit the use of hand gestures when communicating with the client.
Speak to the client with an increased pitch.
Use written materials to assist with communication.
Limit visitors to avoid communication misunderstandings.
The Correct Answer is C
A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.
B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.
C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.
D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Report the finding to the provider. While the provider should be informed if the hypertension is new, persistent, or symptomatic, the nurse should first verify the blood pressure before escalating the concern.
B. Compare the finding to the client's blood pressure baseline. Checking the baseline is important, but the first action should be to confirm the accuracy of the reading by rechecking it. If the reading is consistent with previous values, the nurse can then compare it to the baseline.
C. Administer antihypertensive medications as prescribed. Administering medication without confirming the blood pressure reading could lead to unnecessary treatment or hypotension if the reading was inaccurate. The nurse should first recheck the BP.
D. Recheck the client's blood pressure. Rechecking the blood pressure ensures accuracy before making clinical decisions. Factors such as incorrect cuff size, client positioning, or transient increases (e.g., anxiety or pain) could cause an elevated reading. If the elevated BP is confirmed, then further action (e.g., notifying the provider or administering medication) can be taken.
Correct Answer is D
Explanation
A. Papule – A papule is a raised, solid lesion (e.g., a mole) and is palpable, not flat.
B. Vesicle – A vesicle is a fluid-filled blister (e.g., herpes, chickenpox), which is not the case here.
C. Nodule – A nodule is a deep, raised lesion that extends into the dermis or subcutaneous tissue.
D. Macule – A macule is a flat, nonpalpable skin discoloration that is less than 1 cm (e.g., a freckle or petechiae).
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