A nurse, during a shift report, learns that a patient under their care is blind. What actions by the nurse would demonstrate effective communication?

Introduce self after entering the patient’s room

Use a firm, loud voice when addressing the patient

Lightly touch the patient’s arm

Provide instructions in clear, simple terms .

Answer and Explanation

Correct Answer : A,C,D

Choice A rationale
Introducing oneself after entering the patient’s room is a key aspect of effective communication with a blind patient. This helps the patient identify who is in the room with them.
Choice B rationale
Using a firm, loud voice when addressing the patient is not necessarily effective. While it’s important to speak clearly, raising one’s voice can come off as patronizing or disrespectful. It’s better to speak in a normal tone and adjust as needed based on the patient’s feedback.
Choice C rationale

Lightly touching the patient’s arm can be an effective way to gain their attention, especially if they may not have heard you enter the room. However, it’s important to ask for consent before touching the patient.
Choice D rationale
Providing instructions in clear, simple terms can be very helpful for a blind patient. This can help them understand what is happening and what they need to do.

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Correct Answer is C

Explanation

Choice A rationale
The Rinne test is a hearing test used to evaluate the difference between sound transmission through air conduction versus bone conduction. It is not typically used following a Romberg test, which evaluates balance.
Choice B rationale
While ensuring the patient’s safety is always important, repositioning the client supine is not the typical response to slight swaying during a Romberg test.
Choice C rationale
Slight swaying during a Romberg test is considered normal. Therefore, documenting successful completion of the assessment would be the appropriate action.
Choice D rationale
A referral to a neurologist is not typically necessary for slight swaying during a Romberg test, as this is considered within normal limits.

A. Open the patient’s jaw and insert a mouth gag B. Move furniture away from the patient C. Loosen constrictive clothing D. Provide privacy E. Restrain the patient to avoid self-injury F. Position the patient on their side with their head flexed forward

Correct Answer is ["B","C","D","F"]

Explanation

Choice A rationale
It is a common misconception that something should be placed in the mouth of someone having a seizure to prevent them from biting their tongue. However, this can cause more harm than good, including injury to the person’s mouth or the rescuer’s fingers.
Choice B rationale
Moving furniture away from the person having a seizure can help prevent injury. During a seizure, a person may move uncontrollably, and removing nearby objects can reduce the risk of harm.
Choice C rationale
Loosening constrictive clothing can help the person breathe more easily during and after a seizure.
Choice D rationale
Providing privacy can help maintain the person’s dignity and reduce embarrassment after a seizure.
Choice E rationale
It is not recommended to restrain a person during a seizure. This can result in injury. Instead, the goal is to keep the person safe until the seizure stops on its own.
Choice F rationale

Positioning the person on their side with their head flexed forward can help prevent aspiration, which can occur if the person vomits during or after a seizure.

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A nurse, during a shift report, learns that a patient under their care is blind. What actions by the nurse would demonstrate effective communication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the performance of a Romberg test, the nurse observes the client sway slightly. What action should the nurse take?

Correct Answer is C

Explanation

While waiting for an appointment in the doctor’s office, a patient experiences a convulsive seizure. The nurse is immediately notified. What nursing care should be provided at this time? (Select all that apply.)

Correct Answer is ["B","C","D","F"]

Explanation

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