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: This is the correct answer because bacterial meningitis is a medical emergency that requires immediate antibiotic therapy to prevent complications and death.

Choice B reason: This is incorrect because documenting intake and output is not a priority action for a child with bacterial meningitis. Fluid balance is important, but not as urgent as antibiotic administration.

Choice C reason: This is incorrect because reducing environmental stimuli is a supportive measure that can help reduce headache and photophobia, but it is not a priority action for a child with bacterial meningitis. The nurse should focus on preventing infection spread and monitoring for signs of increased intracranial pressure.

Choice D reason: This is incorrect because maintaining seizure precautions is a preventive measure that can help protect the child from injury, but it is not a priority action for a child with bacterial meningitis. The nurse should administer anticonvulsants as prescribed and observe for seizure activity, but the main goal is to treat the infection.

A. Seasonal allergies B. History of GERD C. Benzodiazepines D. Completed antibiotics 10 days ago

Correct Answer is C

Explanation

Choice A Reason: Seasonal allergies are not a cause of delirium, but a common condition that affects the respiratory system and causes symptoms such as sneezing, runny nose, itchy eyes, or coughing.

Choice B Reason: History of GERD is not a cause of delirium, but a chronic condition that affects the digestive system and causes symptoms such as heartburn, regurgitation, chest pain, or difficulty swallowing.

Choice C Reason: Benzodiazepines are a cause of delirium, especially in older adults or those with cognitive impairment. Benzodiazepines are a class of drugs that act on the central nervous system and cause sedation, relaxation, and reduced anxiety. However, they can also impair memory, attention, orientation, and judgment, and lead to confusion, agitation, hallucinations, or delusions.

Choice D Reason: Completed antibiotics 10 days ago are not a cause of delirium, but a treatment for bacterial infections. Antibiotics can have side effects such as nausea, diarrhea, rash, or allergic reactions, but they do not cause delirium unless they are toxic or interact with other medications.

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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

A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority?

Correct Answer is A

Explanation

A nurse is reviewing the medical record of a client who is experiencing delirium. Which of the following in the health record should the nurse identify as a cause of this disorder?

Correct Answer is C

Explanation

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