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
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.

A. By using the Romberg test B. By assessing the patient’s sensitivity to temperature and touch C. By observing the patient’s response to painful stimuli D. By observing the reaction of pupils to light

Correct Answer is C

Explanation

Choice C rationale
When providing care for a comatose patient, a nurse should evaluate motor responses by observing the patient’s response to painful stimuli. This can be done by applying a painful stimulus, such as a trapezius pinch or nailbed pressure, and observing the patient’s motor response. Purposeful or semi-purposeful movements, such as localizing or withdrawing from pain, can provide valuable information about the patient’s level of consciousness and neurological function.
Choice A rationale
The Romberg test is used to evaluate balance and is not typically used to evaluate motor responses in a comatose patient.
Choice B rationale
Assessing the patient’s sensitivity to temperature and touch can provide information about sensory function, but it does not directly evaluate motor responses.
Choice D rationale

Observing the reaction of pupils to light can provide information about cranial nerve function, but it does not directly evaluate motor responses.

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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

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

When providing care for a comatose patient, how should a nurse evaluate motor responses?

Correct Answer is C

Explanation

The nurse is providing patient education to a patient with early-stage Alzheimer’s disease (AD) and their family. The patient has been prescribed donepezil hydrochloride. What should the nurse explain to the patient and family about this drug?

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

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In the context of outpatient care for a client diagnosed with Bell’s palsy, which of the following statements, if made by the client, would indicate the need for further education?

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The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?