A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

Place a sign on the client's door indicating visual impairment.

Provide the client with a brightly colored plate and utensils.

When ambulating with the client, grasp the client's arm above the elbow.

Speak in an elevated tone of voice when providing care.

Answer and Explanation

The Correct Answer is C

A) Place a sign on the client's door indicating visual impairment:
While indicating the client’s visual impairment to staff can be helpful, privacy and dignity should also be considered. Alternative methods to inform the staff without compromising the client's privacy should be used.

B) Provide the client with a brightly colored plate and utensils:
Brightly colored plates and utensils can help clients with partial vision impairment but may not be significantly beneficial for those who are fully visually impaired.

C) When ambulating with the client, grasp the client's arm above the elbow:
Grasping the client's arm above the elbow is an effective way to guide a visually impaired person. This allows the client to follow the nurse's movements more naturally and ensures better support and guidance.

D) Speak in an elevated tone of voice when providing care:
Elevating the tone of voice is unnecessary and may be misinterpreted as condescending. Clear, normal, and respectful communication is essential for all clients, regardless of visual impairment.

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Correct Answer is A

Explanation

A. Administer a dose of subcutaneous epinephrine.: The swelling of the lips and tongue is indicative of angioedema, a serious adverse reaction to captopril. Epinephrine is the first-line treatment for severe allergic reactions or angioedema to quickly counteract the swelling and prevent airway obstruction.

B. Advise the client not to consume grapefruit products.: Grapefruit can interact with some medications, but it is not related to the management of angioedema. This action would be more relevant for drugs metabolized by CYP3A4, not specifically for angioedema.

C. Place warm compresses on both sides of the client's face.: Warm compresses are not appropriate for angioedema and may not address the underlying issue. This action does not manage the immediate, potentially life-threatening reaction caused by captopril.

D. Swab the client's oral mucosa with nystatin suspension.: Nystatin is used for fungal infections of the oral mucosa, not for angioedema. This action does not address the adverse reaction related to captopril.

A. Reports intolerance to heat B. Develops bradycardia after eating C. Has a friction rub on auscultation D. Displays dyspnea while walking

Correct Answer is D

Explanation

A) Reports intolerance to heat: Intolerance to heat is more commonly associated with conditions like hyperthyroidism rather than iron-deficiency anemia. Individuals with iron-deficiency anemia often experience fatigue and cold intolerance due to decreased oxygen-carrying capacity of the blood.

B) Develops bradycardia after eating: Bradycardia (slow heart rate) is not typically associated with iron-deficiency anemia. Anemia usually causes an increased heart rate (tachycardia) as the body tries to compensate for reduced oxygen delivery.

C) Has a friction rub on auscultation: A friction rub is a sound heard on auscultation associated with pericarditis, an inflammation of the pericardium, and is not a typical finding in iron-deficiency anemia. Anemia primarily affects the blood and does not usually cause inflammation of the heart lining.

D) Displays dyspnea while walking: Dyspnea, or shortness of breath, is a common symptom of iron-deficiency anemia, particularly with exertion. This occurs because the reduced hemoglobin levels result in decreased oxygen delivery to tissues, making physical activities more challenging and causing breathlessness.

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A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is taking captopril and has developed swelling of the lips and tongue. Which of the following actions should the nurse plan to take to manage this adverse medication reaction?

Correct Answer is A

Explanation

A nurse is assessing a client who has iron-deficiency anemia. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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