An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

Have the client vocalize the instructions provided.

Provide written instructions for eye drop administration.

Speak clearly and face the client for lip reading.

Ensure that someone will stay with the client for 24 hours.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A.

Choice A rationale:

Having the client vocalize the instructions provided ensures that they have understood the information correctly. This method allows the nurse to confirm comprehension and clarify any misunderstandings.

Choice B rationale:

Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions. It is a good supplementary measure but should not be the sole method of communication.

Choice C rationale:

Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments. However, it does not guarantee that the client has understood the instructions.

Choice D rationale:

Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.

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Correct Answer is B

Explanation

A) Incorrect- While it's important for UAPs to report changes in a client's condition, the immediate priority is to assess and address the deteriorating condition of the client. The nurse's first action should be to stop the current care being provided and assess the client.
B) Correct- In this situation, the priority is to ensure the safety and well-being of the client. The client's deteriorated condition needs to be assessed promptly by a licensed nurse to determine the appropriate interventions. Stopping the care being provided by the unlicensed assistive personnel (UAP) allows the nurse to focus on the client's immediate needs.
C) Incorrect- Administering oral medications is not the immediate priority in this situation. The client's deteriorating condition takes precedence over administering medications.
D) Incorrect- While investigating the situation and addressing communication gaps is important, the first priority is to assess and address the client's current condition. The nurse needs to take immediate action to ensure the client's safety and well-being.

A. "When did these voices begin?" B. "Do you believe the voices are real?" C. "Are you planning to obey the voices?" D. "Have you taken any hallucinogens?"

Correct Answer is C

Explanation

It is important to determine if the client has any plans or intentions to act upon the voices' instructions. This information helps gauge the level of risk and guides further interventions and safety measures.

While the other questions may also be important to ask during the assessment, determining if the client believes the voices are real and when the voices began can provide valuable information about the client's perception and the duration of the symptoms. Asking about the use of hallucinogens is relevant to identify potential substance-induced causes of the hallucinations. However, assessing the client's intent and potential for harm is the priority in this situation.

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An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

Correct Answer is C

Explanation

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