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.

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Correct Answer is D

Explanation

Victims of intimate partner violence require access to resources and support services to help them navigate their situation and make informed decisions about their safety and well-being.
A. Blaming the victim for the violent behavior of their partner is not only ineffective but also unethical.
B. While providing strategies for interacting with others in social situations may be helpful for general social skills development, it is not directly relevant to addressing the immediate needs of victims of intimate partner violence.
C. Instructing the client on ways to behave to prevent making their partner angry is not appropriate. It implies that the victim is responsible for the abusive behavior of their partner, which is not the case.

A. Assessing the client's neurologic status B. Consulting an allergy specialist C. Administering epinephrine D. Determining the cause of the hives

Correct Answer is C

Explanation

Administering epinephrine is the immediate priority when managing anaphylaxis. Epinephrine is the first-line treatment for anaphylaxis as it helps to rapidly reverse severe allergic symptoms, such as airway constriction, swelling, and hypotension.

A. While assessing the client's neurologic status is important for monitoring their overall condition, it may not be the immediate priority when the client is experiencing symptoms of an allergic reaction, particularly anaphylaxis.

B. While consulting an allergy specialist may be necessary for further evaluation and management of the client's allergic condition, it is not the immediate priority.

D. While determining the cause of the hives is important for identifying the allergen and preventing future allergic reactions, it is not the immediate priority during an acute episode of anaphylaxis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client with an allergic skin condition. The client develops wheezing, a swollen tongue, and hives. Which of the following is the nursing priority?

Correct Answer is C

Explanation

A nurse manager in a community clinic is explaining the concept of culture to a newly licensed nurse. Which of the following statements should the nurse manager use to describe a subculture?

A nurse is asking a client who has schizophrenia about their cultural and spiritual beliefs. Which of the following is the purpose for collecting this information?

A student nurse is preparing a client room for the treatment of an ovarian cyst. What would be least important for the student nurse to do immediately before performing the client's physical exam with the primary nurse? (Select All that Apply.)

A nurse is completing the intake health assessment at a clinic. Which of the following is the priority action for the nurse to take?

A nurse is providing care to a client who asks, "What is the meaning of holistic nursing care?" The nurse should give which of the following responses?

A nurse is interviewing a client during admission to an alcohol treatment center. Which of the following approaches should the nurse take?