A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

Increase her voice when speaking to the client

Lower the bed rails before lowering the bed

Use hand gestures to point to where the client will walk

Stand slightly in front and to one side of the client

Answer and Explanation

The Correct Answer is D

Choice A reason: This is incorrect because increasing her voice when speaking to the client may not prevent complications, but rather annoy or offend the client. The nurse should not assume that a client with a visual impairment has a hearing impairment as well unless it is confirmed by assessment or history. The nurse should speak in a normal tone and volume and identify herself by name and role.
Choice B reason: This is incorrect because lowering the bed rails before lowering the bed may increase the risk of complications, such as falls or injuries. The nurse should keep the bed rails up until the client is ready to get out of bed and lower them only when necessary. The nurse should also lock the wheels of the bed and adjust it to a comfortable height for the client.
Choice C reason: This is incorrect because using hand gestures to point to where the client will walk may not prevent complications, but rather confuse or frustrate the client. The nurse should not use visual cues or gestures that are meaningless to a client with a visual impairment. The nurse should use verbal directions and descriptions instead, such as "The restroom is on your left, about 10 steps away."
Choice D reason: This is correct because standing slightly in front and to one side of the client can prevent complications, such as collisions or falls. The nurse should guide the client by offering her arm or shoulder for support and walking slightly ahead of him or her. The nurse should also warn the client about any obstacles or changes in terrain, such as stairs, doors, or rugs.

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Correct Answer is A

Explanation

Choice A Reason: Sweating and pallor are early signs and symptoms of dumping syndrome, which is a condition where food moves too quickly from the stomach to the small intestine, causing rapid fluid shifts and hormonal changes. Sweating and pallor are caused by hypoglycemia, which occurs when the high concentration of food in the small intestine stimulates insulin secretion.

Choice B Reason: Abdominal cramping and pain are late signs and symptoms of dumping syndrome, which occur about one to three hours after eating. Abdominal cramping and pain are caused by intestinal distension, spasms, and gas formation.

Choice C Reason: Double vision and chest pain are not signs and symptoms of dumping syndrome, but may indicate other serious conditions, such as stroke or heart attack. Double vision and chest pain should be reported to the provider immediately.

Choice D Reason: Bradycardia and indigestion are not signs and symptoms of dumping syndrome, but may be related to other gastrointestinal disorders, such as gastritis or peptic ulcer disease. Bradycardia and indigestion should be evaluated by the provider for further diagnosis and treatment.

A. 9 B. 11 C. 15 D. 13

Correct Answer is A

Explanation

Choice A Reason: This is correct because the patient's Glasgow Coma Scale score is 9. The Glasgow Coma Scale is a tool that assesses the level of consciousness of a patient with a head injury by measuring three parameters: eye opening, verbal response, and motor response. The patient's eye opening score is 3 (opens eyes to verbal command), verbal response score is 4 (confused speech), and motor response score is 2 (withdraws from pain). The total score is the sum of these three scores, which is 9.

Choice B Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 11. To get a score of 11, the patient would need to have a higher motor response score, such as 4 (withdraws to touch) or 5 (localizes to pain).

Choice C Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 15. To get a score of 15, the patient would need to have the highest scores for all three parameters, such as 4 (opens eyes spontaneously), 5 (oriented speech), and 6 (obeys commands).

Choice D Reason: This is incorrect because the patient's Glasgow Coma Scale score is not 13. To get a score of 13, the patient would need to have a higher verbal response score, such as 5 (oriented speech).

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A nurse is assisting a client with a visual impairment to use the restroom. Which of the following actions will the nurse take to prevent complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which findings indicate this occurrence?

Correct Answer is A

Explanation

A patient with a head injury opens his eyes to verbal stimulation, shouts out when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient's Glasgow Coma Scale score?

Correct Answer is A

Explanation

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