A nurse is preparing to reinforce discharge instructions with a client who reports a hearing deficit.
Which of the following actions should the nurse plan to take?
Stand next to the client when speaking.
Provide a copy of the instructions printed in Braille.
Repeat any phrases that the client misunderstands.
Guide the client away from background noise.
The Correct Answer is D
Choice A rationale
Standing next to the client when speaking is generally less effective than facing them directly. Optimal sound transmission and lip-reading are facilitated by the speaker being directly in front of the client, allowing visual cues to supplement the auditory input. This positioning enhances the client's ability to process speech through both visual and auditory pathways, minimizing communication ambiguity.
Choice B rationale
Providing instructions printed in Braille is an accommodation for clients with visual impairments, not primarily for those with a hearing deficit. While a client may have both impairments, the most immediate and specific action for a hearing deficit involves enhancing auditory reception and clarity or providing visual supplements like written text, not a specialized tactile system like Braille.
Choice C rationale
Repeating phrases the client misunderstands may not be sufficient or effective because the client might still not hear or process the information clearly due to the nature of their hearing deficit. Instead of mere repetition, the nurse should rephrase the statement using different words, speak slower, or employ written communication to ensure comprehension and overcome acoustic difficulties.
Choice D rationale
Guiding the client away from background noise is a critical environmental modification that significantly improves the signal-to-noise ratio. By reducing competing sounds, the nurse ensures the client's hearing acuity is maximally focused on the nurse's voice. This adherence to acoustic principles directly enhances the client's ability to perceive and decode speech sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In the NANDA-I taxonomy (North American Nursing Diagnosis Association - International), a modifier is a term added to the diagnostic concept to give additional meaning or specify the area of concern. "Disturbed" is an acceptable modifier often used to describe a change in a specific pattern, such as Disturbed Body Image or Disturbed Sleep Pattern, indicating a problem that needs nursing intervention.
Choice B rationale
"Elderly" is a demographic descriptor and is not an approved NANDA-I modifier because NANDA-I diagnoses are focused on responses to health problems that nurses can treat, not simply demographic groups. Using age categories as modifiers would not provide the specific clinical focus required for a professional nursing diagnosis.
Choice C rationale
While the family is a focus of care, the term "Family" itself is not a standard modifier in the NANDA-I system. NANDA-I diagnoses typically use modifiers like readiness for, impaired, risk for, or ineffective to describe the client's (individual, family, group, or community) state or response, not a broad social unit designation.
Choice D rationale
"Patient" is the recipient of care and is the overall subject of the nursing diagnosis, not a modifier. The NANDA-I diagnosis structure requires a diagnostic concept followed by a modifier (if necessary) and related factors (etiology) or defining characteristics (signs/symptoms), but "Patient" is too vague to act as a descriptor.
Correct Answer is ["A","C"]
Explanation
Choice A rationale
Vomiting 300 cc of green emesis is objective data because it is a measurable and observable sign of nausea, directly verifiable by the nurse. The volume (300 cc) and characteristic (green emesis) are quantifiable physical findings that can be used to assess the severity of the patient's condition, providing evidence beyond the patient's subjective report.
Choice B rationale
Blood pressure of 116/72 mmHg is objective data, a measurable vital sign, but it's often an expected finding (normal range typically <120/80) that doesn't specifically relate to or confirm nausea, though hemodynamic changes can occur with severe vomiting. While objective, it's a general assessment parameter rather than a direct indication of the symptom of nausea.
Choice C rationale
Hyperactive bowel sounds are objective data that are audible and verifiable by the nurse upon auscultation. Increased peristaltic activity is often associated with gastrointestinal irritation or rapid transit, which can be a physical manifestation related to the underlying physiological disturbance causing the subjective sensation of nausea, providing objective evidence.
Choice D rationale
Patient self-report ("the patient reports nausea") is the definition of subjective data. This information is based on the patient's personal experience and perception, which is crucial for assessment but cannot be directly observed or measured by the nurse. It is the chief complaint, not the objective proof.
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