A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include?
Allow the infant to have soft foods.
Maintain elbow restraints on the infant.
Instruct the parents to feed the infant with a spoon.
Tell the parents to avoid brushing the infant's teeth for two weeks.
The Correct Answer is B
The nurse should include maintaining elbow restraints on the infant in the plan of care following cleft palate repair. This helps to prevent the infant from touching their surgical site and disrupting the healing process.
a) Allowing the infant to have soft foods may be appropriate, but it is not the highest priority. The infant's diet should be determined by the provider and based on the infant's individual needs.
c) Instructing the parents to feed the infant with a spoon may be appropriate, but it is not the highest priority. The infant's feeding method should be determined by the provider and based on the infant's individual needs.
d) Telling the parents to avoid brushing the infant's teeth for two weeks may be appropriate, but it is not the highest priority. The infant's oral care should be determined by the provider and based on the infant's individual needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The therapeutic relationship can be described in terms of four sequential phases: preinteraction phase, introduction/orientation phase, working phase, and termination phase . In the working phase, most of the therapeutic interventional activities are carried out . This is the phase where the nurse should help the client develop problem-solving skills.
The other options are not correct because:
a) The preinteraction phase starts when the nurse is given the responsibility to start a therapeutic relationship with a patient.
c) The introduction/orientation phase is the first meeting of the nurse with her client (patient).
d) The termination phase is the final stage of the nurse-client relationship.
Correct Answer is B
Explanation
To effectively communicate with a client who speaks a different language, it is important to use alternative methods of communication. One effective method is to supplement spoken language with pictures or visual aids. This can help bridge the language barrier and enhance understanding between the nurse and the client.
Recognize that the client nodding indicates an understanding of the information: Nodding does not always indicate understanding. It could be a cultural gesture or a sign of politeness. Relying solely on nodding may lead to miscommunication and misunderstanding.
Speak to the client at an increased volume: Speaking louder does not necessarily overcome the language barrier. It may make communication more difficult and could be perceived as rude or intimidating.
Ask a family member of the client to interpret: While involving a family member may seem helpful, it is not always reliable or appropriate. Family members may not be proficient in both languages or may not fully understand medical terminology. Additionally, the client may desire privacy or may not want to burden their family members with the responsibility of interpretation.
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