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.

Answer and Explanation

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.

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

Explanation

Choice A rationale

Avoiding the use of insect repellent on the skin and clothing is not recommended. Insect repellents containing DEET are effective in preventing tick bites, which can transmit Lyme disease. The toxicity of DEET is minimal when used as directed.

Choice B rationale

Avoiding heavily wooded areas and areas with thick underbrush is recommended to reduce the risk of tick exposure. Ticks that carry Lyme disease are commonly found in these environments.

Choice C rationale

Wearing dark clothing is not recommended as it makes it harder to spot ticks. Light-colored clothing is preferable as it allows for easier detection of ticks.

Choice D rationale

Wearing long-sleeved tops and long pants with closed shoes is recommended to minimize skin exposure and reduce the risk of tick bites.

Choice E rationale

Reporting to the primary health care provider immediately for a blood test if a tick is found is not necessary. The presence of a tick does not immediately indicate Lyme disease. Instead, the tick should be removed promptly, and the area should be monitored for signs of infection.

Choice F rationale

Bathing after being in an infested area and inspecting the body carefully for ticks is recommended. This helps in early detection and removal of ticks, reducing the risk of Lyme disease.

A. CD4-T-cell count 180 cells/mm³. B. Positive Western blot test. C. Platelets 150,000/mm³. D. WBC 5,000/mm³.

Correct Answer is A

Explanation

Choice A rationale

A CD4-T-cell count of 180 cells/mm³ indicates severe immunosuppression in a client with HIV, making them highly susceptible to opportunistic infections. This is a critical value that requires immediate attention to prevent life-threatening complications.

Choice B rationale

A positive Western blot test confirms the presence of HIV antibodies but does not indicate the current immune status or the urgency of the client’s condition.

Choice C rationale

Platelets at 150,000/mm³ are within the normal range and do not indicate an immediate threat to the client’s health.

Choice D rationale

A WBC count of 5,000/mm³ is within the normal range and does not indicate an immediate threat to the client’s health.

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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

Which instructions would the nurse provide to the client about the prevention and early detection of Lyme disease? Select all that apply.

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

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Correct Answer is A

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A nurse is admitting a client who has a partial hearing loss.
Which of the following is the priority action by the nurse?