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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The assessment phase of the nursing process involves gathering comprehensive data about the client's health status, including their medical history, current symptoms, and any factors that may impact their care.
A. The implementation phase of the nursing process involves carrying out the plan of care.
B. The planning phase involves developing a comprehensive plan of care based on the client's assessment data and identified needs.
C. The evaluation phase involves assessing the client's response to interventions and determining the effectiveness of the care provided.
Correct Answer is B
Explanation
Malnutrition typically leads to muscle wasting and weakness, including respiratory muscles. As a result, it is more common to see a decrease in vital capacity rather than an increase.
B. Malnutrition can lead to cognitive impairment and decreased mental status due to inadequate nutrient supply to the brain. Deficiencies in essential nutrients such as vitamins and minerals can affect cognitive function, memory, and concentration.
C. Malnutrition is more commonly associated with dry, rough, and scaly skin due to deficiencies in essential fatty acids and vitamins. Moist skin is not typically a finding associated with malnutrition.
D. Heat intolerance is a feature of hyperthyroidism that is not typically seen in malnutrition.
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