The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?

Places colored stickers on faucet handles to indicate temperature.

Uses a heating pad on a low setting to keep warm.

Asks the nurse to test the temperature of the water before entering the bath.

Replaces all lace-up shoes with Velcro straps for ease.

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing colored stickers on faucet handles helps the patient with visual and tactile deficits identify hot and cold water, reducing burn risk. This action demonstrates successful learning of a safety strategy, promoting independence by compensating for sensory impairments and preventing injury from harmful stimuli.

Choice B reason: Using a heating pad, even on low, is risky for a patient with tactile deficits, as they may not feel burns. This does not reflect safe learning, as it increases injury risk rather than mitigating it, making it an incorrect indicator of successful safety strategy adoption.

Choice C reason: Asking the nurse to test water temperature relies on external assistance, not independence. While safe, it does not demonstrate the patient’s ability to manage risks autonomously, which is the goal of the teaching. This action indicates partial understanding, making it less correct.

Choice D reason: Replacing lace-up shoes with Velcro straps improves ease but does not address injury risk from harmful stimuli like heat. This action is unrelated to tactile or visual deficits’ safety concerns, making it an incorrect indicator of successful learning for the taught safety strategies.

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Correct Answer is B

Explanation

Choice A reason: Acknowledging lost energy restates a symptom but does not address the patient’s emotional state. The patient’s statement, “What’s the use?” suggests despair beyond physical fatigue. This response misses the opportunity to explore psychological distress, limiting therapeutic communication and failing to support the patient’s emotional needs in a terminal illness.

Choice B reason: Stating “It sounds like you have lost hope” reflects the patient’s despair, as indicated by disinterest in work, care, and the phrase “What’s the use?” This empathetic response opens dialogue about emotional and spiritual needs, fostering trust. It aligns with holistic care, addressing the psychological impact of a terminal diagnosis effectively.

Choice C reason: Focusing on lost sleep restates a symptom without addressing the underlying hopelessness. Sleep issues are secondary to the patient’s emotional distress in a terminal illness. This response fails to engage with the patient’s despair, missing a chance to provide emotional support and explore deeper psychological or spiritual concerns.

Choice D reason: Noting lost appetite acknowledges a physical symptom but ignores the patient’s emotional withdrawal and hopelessness. The statement “What’s the use?” points to existential distress, not just eating issues. This response lacks depth, failing to address the psychological and spiritual dimensions critical in terminal illness care.

A. Scold the surgeon for not obeying the sign and respecting the patient’s wishes. B. Firmly explain that the patient does not wish to have visitors at this time. C. Allow the surgeon to enter. D. Call for security to remove the surgeon.

Correct Answer is B

Explanation

Choice A reason: Scolding the surgeon is unprofessional and escalates the situation unnecessarily. It fails to respect the colleague’s role while disregarding therapeutic communication. A firm, respectful explanation upholds the patient’s wishes without confrontation, making this an inappropriate response that could harm professional relationships.

Choice B reason: Firmly explaining that the patient does not wish to have visitors respects the patient’s autonomy and the agreed-upon “Do not disturb” sign. This response is professional, assertive, and protects the patient’s need for rest, reducing agitation while maintaining collegiality, making it the most appropriate action.

Choice C reason: Allowing the surgeon to enter disregards the patient’s expressed need for privacy and the “Do not disturb” sign. This undermines trust and exacerbates the patient’s agitation, contradicting the nurse’s role as an advocate. This action fails to prioritize the patient’s well-being, making it incorrect.

Choice D reason: Calling security is an extreme measure, inappropriate for a non-threatening situation. It escalates a manageable interaction and risks damaging professional relationships. A firm explanation is sufficient to enforce the patient’s wishes, making this an overreactive and unnecessary response to the situation.

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The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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