A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?
Guide the client by walking parallel with them.
Use a loud tone of voice when speaking with the client.
Rearrange client’s bedside table items frequently.
Remove objects from client’s path to the bathroom.
The Correct Answer is D
Choice A reason: Guiding the client by walking parallel is less effective than offering an arm for support, which provides stability and orientation. Parallel walking does not ensure safe navigation for someone with visual impairment, as it lacks physical guidance, making it less appropriate for preventing falls or ensuring safety.
Choice B reason: Using a loud tone of voice assumes hearing impairment, which is not indicated in visual sensory loss. Normal volume with clear enunciation is sufficient, and loud tones may be perceived as disrespectful or startling. This intervention is unnecessary and inappropriate for addressing visual impairment, focusing on an irrelevant sensory issue.
Choice C reason: Rearranging bedside table items frequently disorients a visually impaired client, increasing confusion and fall risk. Consistent placement of items supports independence and safety by allowing the client to rely on memory and touch, making this intervention counterproductive and unsafe for the care plan.
Choice D reason: Removing objects from the path to the bathroom prevents tripping hazards, enhancing safety for a client with reduced visual perception. This intervention reduces fall risk, promotes independent mobility, and aligns with evidence-based practices for visually impaired individuals, making it the most effective and appropriate action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Reassuring the client about future children minimizes her current grief and loss, which is inappropriate during initial grieving. This dismisses the emotional significance of the stillbirth, potentially causing distress, making it an insensitive and incorrect action.
Choice B reason: Discouraging friends from seeing the newborn restricts the client’s support system and grieving process. Allowing such interactions can provide closure and comfort, so this action is counterproductive and insensitive, making it incorrect for supporting grief.
Choice C reason: Offering to take pictures of the newborn provides a tangible memory, supporting the client’s grieving process. This sensitive intervention validates the loss and aids emotional healing, aligning with best practices for stillbirth care, making it the correct action.
Choice D reason: Advising against discussing the stillbirth isolates the client and hinders grief processing. Open communication with family fosters support and healing, so this action is harmful and contradicts grief support principles, making it incorrect.
Correct Answer is A
Explanation
Choice A reason: Discussing the prescription with the provider is critical, as amoxicillin, a penicillin derivative, is contraindicated in clients with penicillin allergies due to risk of anaphylaxis. This ensures patient safety by verifying or correcting the order, aligning with nursing advocacy and safety protocols, making it correct.
Choice B reason: Administering amoxicillin to a client with a penicillin allergy risks severe allergic reactions, including anaphylaxis, violating patient safety principles. Nurses must verify contraindicated orders before administration, making this action dangerous and incorrect in this scenario.
Choice C reason: Placing an incident report is premature, as no error has occurred yet. The nurse’s role is to prevent harm by addressing the contraindicated prescription proactively. This action does not resolve the issue and is inappropriate as the first step, making it incorrect.
Choice D reason: Calling the pharmacist for clarification is less direct than discussing with the provider, who issued the order. While pharmacists can provide guidance, the provider must confirm or change the prescription to ensure safety, making this action secondary and less effective.
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