A nurse in an outpatient clinic is caring for a client. Which of the following findings indicates the client is experiencing a hearing deficit?

Rationale

A. Assist the client in discussing their feelings about having diabetes mellitus: This action targets the affective domain of learning, which focuses on emotions, attitudes, and values. It helps the client process feelings about their diagnosis but does not develop hands-on skills or motor abilities.

B. Ask the client to attend a class about following a diabetic diet: Attending a class primarily addresses the cognitive domain by providing knowledge about nutrition and meal planning. It supports understanding but does not involve practicing physical skills or motor tasks.

C. Show the client a video about self-administration of insulin: Demonstrating a skill via video engages the cognitive and observational aspects of learning, but it does not ensure the client can perform the skill. Psychomotor learning requires active hands-on practice.

D. Observe the client practice self-monitoring of blood glucose levels: Observing and guiding the client as they perform the task addresses the psychomotor domain, which involves acquiring and demonstrating physical skills. Hands-on practice with feedback ensures the client develops competence in self-care activities.

Rationale

A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding.

B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation.

C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety.

D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.