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) "I will expect to have to strain while having a bowel movement":
Straining during bowel movements should be avoided as it can increase abdominal pressure and strain on the surgical site, potentially leading to complications such as bleeding or increased discomfort.

B) "I'll plan to restrict my fluid intake to 1 liter per day":
Fluid restriction is not typically advised after a transurethral resection of the prostate (TURP). Adequate fluid intake is important to help flush the bladder and reduce the risk of blood clots and urinary tract infections.

C) "I might have the urge to urinate while I have the catheter in place":
It is common for clients to feel the urge to urinate while a catheter is in place due to the pressure of the catheter on the bladder neck. This statement indicates an understanding of the postoperative experience and normal sensations.

D) "I'll keep my leg flexed if the catheter is taped to my leg":
Keeping the leg flexed is not necessary for catheter management. The catheter should be securely taped to the leg to prevent movement and minimize discomfort, but the position of the leg is not a critical factor in its management.

A. Diarrhea B. Bradycardia C. Tinnitus D. Tetany

Correct Answer is D

Explanation

A) Diarrhea: Metabolic alkalosis is more likely to be associated with constipation rather than diarrhea. Diarrhea is typically a cause of metabolic acidosis due to the loss of bicarbonate in stool, rather than a result of metabolic alkalosis.

B) Bradycardia: Bradycardia is not a typical manifestation of metabolic alkalosis. Alkalosis can lead to arrhythmias, but it generally does not cause a slow heart rate. Instead, tachycardia might occur as the body compensates for the altered acid-base balance.

C) Tinnitus: Tinnitus is not a common symptom of metabolic alkalosis. It is more often associated with aspirin toxicity or other conditions affecting the auditory system, rather than changes in acid-base balance.

D) Tetany: Tetany is a common manifestation of metabolic alkalosis. The alkalosis causes a decrease in ionized calcium levels, which increases neuromuscular excitability and can lead to muscle cramps, spasms, and tetany. This is a key sign for nurses to monitor as it indicates significant electrolyte disturbances associated with the alkalotic state.

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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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Explanation

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