A nurse is caring for a client who is postoperative.
Vital Signs.
0800: Nurses' Notes.
BP 118/72 mm Hg. Heart rate 82/min.
Respiratory rate 16/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
1000: BP 128/82 mm Hg. Heart rate 94/min.
Respiratory rate 18/min.
Temperature 36.7°C (98°F). SaO2 98% on room air.
Vital Signs.
Nurses' Notes.
0745: Client awake and eating breakfast while watching the news on television.
Client has hearing loss, does not wear a 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: Nurses' Notes.
Client ambulated in the hallway with a physical therapist.
Client grimacing, appears upset, and is guarding incisional site.
Reports pain as 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.
1300: Ate 75% of lunch.
Several visitors at the bedside.
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,B,C,E,F
The correct answers are a. Client's hearing deficit, b. Volume of the client's television, c. Numerous visitors in the client's room, e. Adverse effects of opioid analgesic, and f. Using earphones while listening to music.
Choice A rationale: A client with hearing loss who does not wear a hearing aid may experience difficulty understanding spoken communication, especially in noisy environments, leading to potential miscommunication or misunderstanding.
Choice B rationale: Loud television volume can make it difficult for both the nurse and the client to hear each other, causing interference in their communication and potentially leading to errors in information exchange.
Choice C rationale: The presence of numerous visitors in the room can cause distractions, background noise, and overall interference with the nurse-client communication process, potentially affecting the quality and accuracy of the information exchanged.
Choice E rationale: Opioid analgesics can cause adverse effects such as drowsiness, confusion, or cognitive impairment, hindering effective communication between the nurse and the client, as the client's ability to comprehend, retain, and convey information may be impaired.
Choice F rationale: The use of earphones while listening to music can impair the client's ability to hear the nurse, creating a barrier to effective communication. This could potentially lead to missed or misunderstood information and, consequently, affect the quality of care.
Choice D rationale (Incorrect choice): While an increase in pain after ambulation could affect the client's mood, cooperation, and ability to engage in effective communication, it does not directly create a barrier to the nurse's ability to communicate with the client. Pain management is an essential aspect of postoperative care, and effective communication can actually facilitate pain assessment, management, and overall client well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Tell the APs they are acting immature. Telling the APs that they are acting immature is a judgmental and unhelpful approach. It does not demonstrate conflict resolution but rather exacerbates the conflict. This choice is not appropriate for resolving the situation.
Choice B rationale:
Allow the APs to resolve their issues. While allowing individuals to resolve their issues on their own can sometimes work, it is not always the best approach, especially in a healthcare setting where teamwork and patient care are paramount. In this scenario, the nurse should play an active role in resolving the conflict, making this choice less suitable.
Choice C rationale:
Confront the APs to discuss their argument. Confronting the APs to discuss their argument is a proactive approach to conflict resolution. It allows the nurse to address the issue, mediate the disagreement, and work towards a resolution. This choice is the most appropriate and demonstrates effective conflict resolution.
Choice D rationale:
Report the APs to the charge nurse. Reporting the APs to the charge nurse should be considered when the conflict cannot be resolved at the staff level, and it threatens patient care or safety. However, it should not be the first step in resolving a conflict between two individuals. It is a more formal and escalated approach, and in this case, choice C is a more suitable initial response.
Correct Answer is ["A","B","C","D"]
Explanation
Findings that Could Increase Susceptibility to Infection:
-
Budesonide 6 mg PO daily:
- Explanation: Budesonide is a corticosteroid used to reduce inflammation, often prescribed for conditions like Crohn's disease. While it helps manage inflammation, corticosteroids also suppress the immune system. This immunosuppressive effect can increase the client's susceptibility to infections.
-
BMI of 16:
- Explanation: A BMI of 16 is considered underweight. Malnutrition or being underweight can weaken the immune system, making a person more susceptible to infections because their body lacks the necessary nutrients and energy to support immune function.
-
History of Type 2 Diabetes Mellitus:
- Explanation: Diabetes, particularly if not well-controlled, can impair the immune system and increase the risk of infections. High blood sugar levels can hinder the function of immune cells, making it easier for infections to develop and harder for the body to fight them.
-
New Diagnosis of Crohn's Disease:
- Explanation: Crohn's disease is an inflammatory bowel disease that causes inflammation of the digestive tract. This chronic inflammation can affect the body's ability to absorb nutrients, leading to nutritional deficiencies that impair the immune system. Additionally, the disease itself, especially when active, can increase the risk of infection.
Findings That Do Not Increase Susceptibility to Infection:
-
Hematocrit (Hct) of 47%:
- Explanation: The Hct level is within the normal range of 37% to 52%. It measures the percentage of red blood cells in the blood. Since it's normal, it does not indicate an increased risk of infection.
-
Hemoglobin (Hgb) of 16 g/dL:
- Explanation: The Hgb level is also within the normal range of 12 to 18 g/dL. Hemoglobin is a protein in red blood cells that carries oxygen. This normal level does not suggest a higher risk of infection.
-
Potassium level of 3.6 mEq/L:
- Explanation: Potassium levels are within the normal range of 3.5 to 5.0 mEq/L. This electrolyte level is unrelated to infection risk in the context provided.
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