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 A

Explanation

Choice A rationale
Instructing the client on daily muscle stretching can help alleviate and relax muscle spasms, which is beneficial for a client diagnosed with multiple sclerosis.

Choice B rationale
Ordering a low-residual diet is not typically a part of the care plan for a client diagnosed with multiple sclerosis.
Choice C rationale
Encouraging the client to void every hour may not be necessary for a client diagnosed with multiple sclerosis, unless there are specific urinary symptoms present.
Choice D rationale
Providing total assistance with all activities of daily living may not be necessary for a client diagnosed with multiple sclerosis, as the level of assistance required can vary greatly depending on the severity of the disease.

A. The patient has angina B. The patient has a history of asthma C. The patient is 75 years old D. The patient’s migraines are associated with psychosocial stress

Correct Answer is A

Explanation

Choice A rationale
Triptans, a class of medications commonly used to treat migraines, can cause vasoconstriction, or narrowing of the blood vessels. This can be problematic for patients with angina, a condition characterized by reduced blood flow to the heart. Vasoconstriction could potentially exacerbate this condition, leading to an increased risk of a heart attack. Therefore, the use of triptans may be contraindicated in patients with angina.

Choice B rationale
While asthma is a serious condition that requires careful management, it is not typically considered a contraindication for the use of triptans. Triptans work primarily on the blood vessels in the brain and do not typically interact with the bronchial tubes affected by asthma.
Choice C rationale
Age alone is not typically a contraindication for the use of triptans. However, older adults may have a higher risk of certain health conditions, such as heart disease, which could make the use of triptans more risky. It’s important for healthcare providers to consider the overall health status of the patient, not just their age, when deciding whether to prescribe triptans.
Choice D rationale
While stress can certainly exacerbate migraines, it is not typically a contraindication for the use of triptans. Triptans are designed to relieve the pain and other symptoms of migraines, regardless of their cause. If a patient’s migraines are triggered by stress, it may be beneficial to explore stress management techniques in addition to medication.

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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

The nurse is creating a plan of care for a client who has a recent diagnosis of multiple sclerosis. Which of the following should the nurse include in the client’s care plan?

Correct Answer is A

Explanation

A nurse is caring for a patient with a recent history of migraines. What aspect of this patient’s current status may contraindicate the safe use of triptans?

Correct Answer is A

Explanation

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The nurse is assessing a patient’s visual acuity using a Snellen chart. The patient states he cannot see the top of the chart. What action should the nurse take?

A client is newly diagnosed with relapsing-remitting multiple sclerosis (RRMS). What instruction should the nurse provide?

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