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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because phototherapy is not a recommended therapy for contact dermatitis. Phototherapy involves exposing the skin to artificial light sources that emit specific wavelengths of light that can have anti-inflammatory or immunomodulatory effects. Phototherapy can be used for some skin conditions, such as psoriasis or eczema, but not for contact dermatitis.
Choice B Reason: This is incorrect because antibiotics are not a recommended therapy for contact dermatitis. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Contact dermatitis is not an infection, but an allergic or irritant reaction to a substance that comes in contact with the skin. Antibiotics have no effect on contact dermatitis and may cause adverse effects or resistance.
Choice C Reason: This is incorrect because UV light is not a recommended therapy for contact dermatitis. UV light refers to ultraviolet radiation from sunlight or artificial sources that can damage DNA and cause skin cancer or aging. UV light can also worsen contact dermatitis by increasing inflammation and sensitivity to allergens or irritants.
Choice D Reason: This is correct because avoidance is the best therapy for contact dermatitis. Avoidance means identifying and avoiding the substance that causes the skin reaction. This can prevent further exposure and allow the skin to heal. The nurse can help the client by providing education on how to read labels, use protective clothing or gloves, or substitute safer products.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because observing the client swallowing small sips of water before assisting with feeding may not reduce the risk of aspiration pneumonia. Water is a thin liquid that can easily enter the lungs if the client has impaired swallowing or cough reflexes. The nurse should assess the client's need for thickened liquids or pureed foods and use a swallow screening tool to determine the appropriate consistency and amount of food and fluids.
Choice B Reason: This is incorrect because turning on the television for the client during meals may increase the risk of aspiration pneumonia. Television can distract the client from focusing on chewing and swallowing and cause them to eat too fast or too much. The nurse should provide a quiet and calm environment for the client during meals and encourage them to eat slowly and carefully.
Choice C Reason: This is incorrect because instructing the client to tilt their head back while swallowing may increase the risk of aspiration pneumonia. Tilting the head back can open the airway and allow food or fluids to enter the lungs. The nurse should instruct the client to tilt their head forward or tuck their chin while swallowing, which can close the airway and prevent aspiration.
Choice D Reason: This is correct because sitting the client upright 90 degrees then assisting the client with feeding can reduce the risk of aspiration pneumonia. Sitting upright can help gravity move food and fluids down the esophagus and away from the lungs. The nurse should also keep the client upright for at least 30 minutes after eating and drinking to prevent regurgitation and aspiration.
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