A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?

Limit the use of hand gestures when communicating with the client.

Speak to the client with an increased pitch.

Use written materials to assist with communication.

Limit visitors to avoid communication misunderstandings.

Answer and Explanation

The Correct Answer is C

A. Limit the use of hand gestures when communicating with the client. Hand gestures enhance communication for clients with hearing loss. Visual cues such as gestures, facial expressions, and lip reading can help improve understanding.

B. Speak to the client with an increased pitch. Speaking in an increased pitch is not recommended because higher frequencies are often harder for clients with hearing loss to detect. Instead, the nurse should speak clearly, slowly, and in a lower tone.

C. Use written materials to assist with communication. Written materials help clients with hearing loss understand important information, especially if they rely on lip reading or have significant hearing impairment.

D. Limit visitors to avoid communication misunderstandings. Limiting visitors is unnecessary and may lead to social isolation. Instead, the nurse should encourage communication using appropriate strategies, such as writing or sign language.

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Correct Answer is D

Explanation

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

A. Mix the medications together and administer through the NG tube. B. Crush the sublingual medication into powder form. C. Dissolve crushed tablet medications in sterile water. D. Flush the tube with 5 mL saline between each medication.

Correct Answer is C

Explanation

A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.

B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.

C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.

D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.

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A nurse is completing an admission assessment for a client who has hearing loss. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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