A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?
Rephrase statements the client does not hear.
Determine if the client uses hearing aids.
Speak using his usual tone of voice and directly in front of the client.
Use hand gestures to communicate.
The Correct Answer is B
Choice A rationale
Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.
Choice B rationale
Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.
Choice C rationale
Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.
Choice D rationale
Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
A nagging cough is one of the seven warning signs of cancer. Persistent coughing or hoarseness can indicate lung cancer or other cancers affecting the respiratory system. It is important to investigate any chronic cough that does not resolve with standard treatment.
Choice B rationale
A non-healing sore is another warning sign of cancer. Sores that do not heal, especially in the mouth or on the skin, can be indicative of skin cancer or oral cancer. These sores may bleed, ooze, or become crusty and should be evaluated by a healthcare provider.
Choice C rationale
A change in moles is a significant warning sign of skin cancer, particularly melanoma. Changes in size, shape, color, or texture of a mole, or the appearance of new moles, should be assessed by a healthcare provider. Early detection of skin changes can lead to prompt treatment and better outcomes.
Choice D rationale
A change in bowel pattern is a warning sign of colorectal cancer. Symptoms such as persistent diarrhea, constipation, or changes in stool consistency or color can indicate an underlying malignancy in the digestive tract. It is important to seek medical evaluation for any unexplained changes in bowel habits.
Choice E rationale
Bloating is not typically included in the seven warning signs of cancer. While bloating can be a symptom of various conditions, including ovarian cancer, it is not one of the primary warning signs used to identify cancer. The focus should be on the more specific signs listed above. .
Correct Answer is B
Explanation
Choice B rationale
The FLACC scale (Face, Legs, Activity, Cry, Consolability) is specifically designed for assessing pain in infants and young children who are unable to communicate their pain verbally.
Choice A rationale
The Visual Analog Scale is used for older children and adults who can understand and communicate their pain level.
Choice C rationale
The Oucher scale is used for children aged 3 to 12 years and involves matching facial expressions to a pain level.
Choice D rationale
The Faces scale is used for children aged 3 years and older who can point to a face that best represents their pain level.
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