A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

Place a sign on the client's door indicating visual impairment.

Provide the client with a brightly colored plate and utensils.

When ambulating with the client, grasp the client's arm above the elbow.

Speak in an elevated tone of voice when providing care.

Answer and Explanation

The Correct Answer is C

A) Place a sign on the client's door indicating visual impairment:
While indicating the client’s visual impairment to staff can be helpful, privacy and dignity should also be considered. Alternative methods to inform the staff without compromising the client's privacy should be used.

B) Provide the client with a brightly colored plate and utensils:
Brightly colored plates and utensils can help clients with partial vision impairment but may not be significantly beneficial for those who are fully visually impaired.

C) When ambulating with the client, grasp the client's arm above the elbow:
Grasping the client's arm above the elbow is an effective way to guide a visually impaired person. This allows the client to follow the nurse's movements more naturally and ensures better support and guidance.

D) Speak in an elevated tone of voice when providing care:
Elevating the tone of voice is unnecessary and may be misinterpreted as condescending. Clear, normal, and respectful communication is essential for all clients, regardless of visual impairment.

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Correct Answer is C

Explanation

A) A school-age child who is 2 days postoperative following an appendectomy and has a nasogastric tube: While this child requires regular monitoring and care, they are in a stable postoperative phase and do not show signs of acute distress that necessitate immediate attention over other clients.

B) A preschooler awaiting discharge instructions prior to leaving the hospital: This client is stable enough to be considered for discharge. While discharge instructions are important, they do not take priority over a client with potential respiratory distress.

C) A toddler who has a respiratory rate of 54/min: This client exhibits a significantly elevated respiratory rate, which can indicate respiratory distress or a serious underlying condition. Immediate assessment and intervention are necessary to ensure the toddler's airway and breathing are managed appropriately.

D) A school-age child who reports nausea following chemotherapy: While nausea following chemotherapy is uncomfortable and needs management, it is a known side effect and typically not life-threatening. This client's condition is less urgent compared to a toddler showing signs of potential respiratory distress.

A. Press down on the canister top. B. Attach the spacer. C. Shake the haler. D. Hold breath for 10 seconds. E. Place lips around the mouthpiece.

Correct Answer is B,C,E,A,D

Explanation

B. Attach the spacer.: Attaching the spacer first ensures that the inhaler is properly connected and ready for use.

C. Shake the inhaler.: Shaking the inhaler is essential to mix the medication thoroughly before use.

E. Place lips around the mouthpiece.: Placing the lips around the mouthpiece is done while the inhaler is ready to be activated.

A. Press down on the canister top.: Pressing the canister releases the medication into the spacer, which the client will then inhale.

D. Hold breath for 10 seconds.: Holding the breath allows the medication to be fully absorbed into the lungs.

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A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is B,C,E,A,D

Explanation

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