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 B

Explanation

A) Bicarbonate 26 mEq/L: A bicarbonate level of 26 mEq/L is within the normal range (22-28 mEq/L) and does not indicate metabolic acidosis, which is characteristic of diabetic ketoacidosis (DKA). In DKA, bicarbonate levels are usually decreased due to buffering of the excess acids.

B) Serum pH 7.32: A serum pH of 7.32 is indicative of acidemia, which is consistent with metabolic acidosis seen in DKA. The pH is typically lower than the normal range (7.35-7.45) in DKA due to the accumulation of ketoacids.

C) Creatinine 1.2 mg/dL: A creatinine level of 1.2 mg/dL is slightly elevated but does not specifically indicate metabolic acidosis. Elevated creatinine may suggest renal impairment but is not directly linked to the acid-base disturbance seen in DKA.

D) BUN 20 mg/dL: A blood urea nitrogen (BUN) level of 20 mg/dL is elevated and may indicate dehydration or kidney dysfunction but does not specifically diagnose the acid-base imbalance associated with DKA. In DKA, bicarbonate and pH levels are more directly affected.

A. It manifests as a sense of relief upon the loved one's death. B. It causes a prolonged grief response to occur. C. It occurs when the loss of a loved one cannot be shared openly. D. It remains difficult to process due to a lack of finality.

Correct Answer is B

Explanation

A) It manifests as a sense of relief upon the loved one's death: This describes a possible outcome of anticipatory grief but does not define anticipatory grief itself. While relief can be a reaction, it is not the core characteristic of anticipatory grief.

B) It causes a prolonged grief response to occur: Anticipatory grief involves experiencing grief before the actual loss occurs. This process can sometimes lead to a prolonged grief response, as individuals might go through stages of grief before and after the loss.

C) It occurs when the loss of a loved one cannot be shared openly: This describes disenfranchised grief, which happens when the loss is not socially acknowledged or supported. Anticipatory grief occurs prior to the loss, not due to a lack of social support.

D) It remains difficult to process due to a lack of finality: While anticipatory grief can be challenging due to ongoing uncertainties and emotional strain, it is not primarily defined by a lack of finality. The grief occurs as individuals anticipate the impending 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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