A nurse is caring for a client who has a moderate vision impairment. Which of the following actions should the nurse take?

Face the client when speaking to them.

Open shades on windows in the client's room to provide direct lighting

Use gestures to communicate with the client.

Speak loudly when talking to the client.

Answer and Explanation

The Correct Answer is A

A. Face the client when speaking to them. This is the correct action. Facing the client while speaking helps them use any remaining vision they have to interpret facial expressions and lip movements, which can enhance communication.

B. Open shades on windows in the client's room to provide direct lighting. Direct lighting can cause glare, which may worsen vision impairment. It is better to use indirect lighting to avoid glare.

C. Use gestures to communicate with the client. While gestures can be useful for some individuals, they are not as effective for clients with vision impairment who may not be able to see them clearly.

D. Speak loudly when talking to the client. There is no need to speak loudly unless the client also has a hearing impairment. Speaking loudly could be perceived as shouting, which may be uncomfortable for the client.

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Correct Answer is A

Explanation

A. Reflex incontinence: Reflex incontinence occurs when the bladder muscle contracts and urine leaks out (often in large amounts) without any warning or urge. This is common in clients with nerve damage or spinal cord injuries, making it the correct answer.

B. Urge incontinence: Urge incontinence is characterized by a sudden, intense urge to urinate followed by involuntary urine loss. It is often associated with an overactive bladder, not nerve damage.

C. Stress incontinence: Stress incontinence involves urine leakage during physical activity or exertion (e.g., coughing, sneezing) that increases abdominal pressure. It is not typically related to nerve damage.

D. Overflow incontinence: Overflow incontinence occurs when the bladder is unable to empty properly, leading to dribbling of urine. It is often seen in conditions where the bladder muscles are weak or there is an obstruction. While it can be related to nerve damage, reflex incontinence is more accurate for this scenario.

A. Secure new tracheostomy ties before removing old ones. B. Use aseptic technique. C. Apply suction when inserting the catheter. D. Clean the inner cannula with mild soap and water.

Correct Answer is A

Explanation

A. Secure new tracheostomy ties before removing old ones. Securing the new ties before removing the old ones prevents accidental decannulation of the tracheostomy tube.

B. Use aseptic technique. Aseptic technique should be used to reduce the risk of infection during tracheostomy care.

C. Apply suction when inserting the catheter. Suction should only be applied when withdrawing the catheter, not during insertion, to prevent trauma to the trachea and bronchial tissues.

D. Clean the inner cannula with mild soap and water. The inner cannula should be cleaned with sterile saline or a prescribed solution, not with soap, to avoid irritation and infection.

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A nurse is caring for a client who has a moderate vision impairment. Which of the following actions should the nurse take?

Nursing Test Bank

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