A nurse is caring for a client who is postoperative. Nurses' Notes

0745:

Client awake and eating breakfast while watching the news on television. Client has hearing loss, does not wear hearing aid, and TV volume is loud. Rates pain as a 2 on a 0 to 10 pain scale.

Incisional dressing dry and intact. 1000:

Client ambulated in hallway with physical therapist. Client grimacing. appears upset and is guarding incisional site. Reports pain a 5 on a 0 to 10 pain scale. Opioid analgesic administered.

1045

Client resting with eyes closed and listening to music with earphones. Reports feeling "very sleepy after pain medication. Now rates pain as a 3 on a 0 to 10 pain scale.
Which of the following factors could present a barrier to the nurse effectively communicating with the client? (Select all that apply).

Client's hearing deficit

Volume of the client's television

Numerous visitors in the client's room

Increase in pain after ambulation

Adverse effects of opioid analgesic

Using earphones while listening to music

Answer and Explanation

Correct Answer : A,C,D,E,F

The client's hearing deficit can certainly present a barrier to effective communication, as it may affect their ability to hear and understand verbal instructions or information provided by the nurse.
B.   The loud volume of the client's television is not a barrier in this case as the client has hearing loss.
C.   Having numerous visitors in the client's room can create distractions and make it challenging for the nurse to engage in private, focused communication with the client.
D.   An increase in pain after ambulation can impact the client's ability to focus and engage in effective communication. The client may be preoccupied with managing their pain, which can hinder their receptiveness to communication from the nurse.
E.   Adverse effects of opioid analgesic: Adverse effects of opioid analgesics, such as drowsiness or sedation, can impair the client's cognitive function and alertness, making it difficult for them to participate actively in communication with the nurse.
F.   Using earphones while listening to music may create a physical barrier to communication, as it limits the nurse's ability to speak directly to the client or gain their attention.

Nursing Test Bank

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Correct Answer is A

Explanation

Caring for diverse clients will require balancing differences and needs acknowledges the importance of recognizing and respecting cultural diversity among clients. Each individual may have unique cultural backgrounds, beliefs, values, and needs. The nurse must balance these differences effectively to provide care that is sensitive to each client's cultural context.
B. It assumes homogeneity among individuals within the same neighborhood, disregarding the reality of cultural diversity even within small geographic areas.
C. It suggests that all clients, regardless of cultural background, should receive the same standard of care.
D. It disregards the importance of considering clients' cultural diversity in developing the plan of care.

A. Assess the child without their caregiver present. B. Have toys or drawing materials available for the child. C. Focus on the physical domain of health. D. Have the child carefully repeat the events of the trauma.

Correct Answer is B

Explanation

B. Providing toys or drawing materials can help the child express their thoughts, feelings, and experiences in a nonverbal and developmentally appropriate manner. Play-based activities allow children to communicate and process their emotions more comfortably than verbal communication alone.

For young children, especially those who have experienced trauma, the presence of a caregiver can provide comfort, reassurance, and support during the assessment process.

C. Neglecting the child's emotional needs can result in overlooking important aspects of their experience and hinder their recovery.

D. Asking the child to repeat the events of the trauma can be retraumatizing and overwhelming for them. It may increase their distress and hinder their ability to cope with the experience.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse cares for a neighborhood of diverse clients. Which of the following aspects of cultural diversity should the nurse remember when caring for the clients?

Correct Answer is A

Explanation

A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client?

Correct Answer is B

Explanation

A nurse is caring for a client who has limited hand movement. Which of the following actions should the nurse take to assist the client with feeding?

A nurse manager in a community clinic is planning an in-service to increase staff nurses' knowledge on cultural diversity in health care. Which of the following information should the nurse manager include in the presentation? (Select All that Apply)

A nurse is assessing a toddler at a well-child visit. At what point in the physical examination should the nurse examine the child's tympanic membrane?

During an assessment, the nurse determines that a client sees more than one primary care provider and has obtained prescriptions from each provider. Which method would be most appropriate to determine a client's current medication regimen?

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

A nurse manager is evaluating the performance of a newly licensed nurse after performing a client interview. Which of the following nonverbal actions by the newly licensed nurse should be identified as appearing too relaxed?

A nurse in an emergency department often sees victims of intimate partner violence. Which of the following actions should the nurse take when caring for victims of violence?