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.

Answer and Explanation

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.

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Free Nursing Study Resources

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

Explanation

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

A. Client appears anxious B. Mucous membranes cyanotic C. S1, S2 auscultated, no murmur D. Skin warm and dry E. Respiratory rate 27/min F. Oxygen saturation 84% on 3L nasal cannula

Correct Answer is ["A","B","E","F"]

Explanation

Oxygen Saturation: 84% on 3L nasal cannula

The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.

Mucous Membranes Cyanotic

Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.

Respiratory Rate: 27/min (Increased from 22/min)

An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.

Client Appears Anxious

Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.

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A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

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

Explanation

Correct Answer is ["A","B","E","F"]

Explanation

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