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 C

Explanation

A) "I will expect to have to strain while having a bowel movement":
Straining during bowel movements should be avoided as it can increase abdominal pressure and strain on the surgical site, potentially leading to complications such as bleeding or increased discomfort.

B) "I'll plan to restrict my fluid intake to 1 liter per day":
Fluid restriction is not typically advised after a transurethral resection of the prostate (TURP). Adequate fluid intake is important to help flush the bladder and reduce the risk of blood clots and urinary tract infections.

C) "I might have the urge to urinate while I have the catheter in place":
It is common for clients to feel the urge to urinate while a catheter is in place due to the pressure of the catheter on the bladder neck. This statement indicates an understanding of the postoperative experience and normal sensations.

D) "I'll keep my leg flexed if the catheter is taped to my leg":
Keeping the leg flexed is not necessary for catheter management. The catheter should be securely taped to the leg to prevent movement and minimize discomfort, but the position of the leg is not a critical factor in its management.

A. A client refuses to discuss treatment options with her provider following a terminal diagnosis. B. A client promises a higher power to live a better life if his cancer is healed. C. A client withdraws from his social network following the death of a loved one. D. A client yells at healthcare staff following the death of a loved one.

Correct Answer is A

Explanation

A) A client refuses to discuss treatment options with her provider following a terminal diagnosis: This behavior exemplifies denial, the first stage in Kübler-Ross's five stages of grief. In this stage, individuals are unable to accept the reality of their situation, often refusing to acknowledge the facts and avoiding discussions that might confirm the severity of their condition.

B) A client promises a higher power to live a better life if his cancer is healed: This illustrates the bargaining stage, where individuals attempt to negotiate or make deals with a higher power or fate to reverse or delay the loss or illness. They hope that by promising to change their behavior, they can influence the outcome.

C) A client withdraws from his social network following the death of a loved one: Withdrawal from social interactions is indicative of the depression stage, where individuals may feel profound sadness, hopelessness, and a desire to isolate themselves as they process the magnitude of their loss.

D) A client yells at healthcare staff following the death of a loved one: This behavior is characteristic of the anger stage, where individuals express their frustration and helplessness through anger, often directed at people around them, including healthcare providers. This stage reflects the struggle to find meaning and control in the face of loss.

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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?

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