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) Multiple clots in the client's urinary bag:
Multiple clots in the urinary bag can be expected after a transurethral resection of the prostate (TURP) as part of the normal postoperative bleeding. While clots can cause concern if they become excessive or obstructive, they are not as immediately critical as a persistent obstruction.

B) Client reports bladder spasms when repositioning in bed:
Bladder spasms are a common postoperative symptom following TURP and can be managed with antispasmodic medications and proper catheter care. Although uncomfortable, bladder spasms do not pose an immediate threat to the client’s health.

C) Obstruction in client's urinary catheter continues after manual irrigation:
A persistent obstruction in the urinary catheter after manual irrigation is a significant concern. This can indicate a severe blockage that might prevent urine from draining, leading to bladder distention, potential damage to the surgical site, and increased risk of infection. Immediate intervention is required to resolve the obstruction and ensure proper urinary drainage.

D) Client reports a pain rating of 3 on a 0 to 10 scale:
A pain rating of 3 on a 0 to 10 scale indicates mild pain, which is common in the postoperative period and can be managed with analgesics. While pain management is important, this level of pain does not constitute an urgent issue requiring immediate reporting to the provider.

A. Consume 2,800 calories daily during the third trimester. B. Distribute daily calories among three meals and three snacks. C. Maintain a blood glucose level between 100 to 130 mg/dL before meals. D. Restrict daily carbohydrate intake to 60% of total caloric intake.

Correct Answer is B

Explanation

A. Consume 2,800 calories daily during the third trimester.: The caloric needs during pregnancy vary, but 2,800 calories might be excessive for someone with gestational diabetes. The focus should be on maintaining a balanced diet that helps control blood glucose levels rather than meeting a specific caloric target.

B. Distribute daily calories among three meals and three snacks.: Distributing calories throughout the day with balanced meals and snacks can help manage blood glucose levels and prevent significant spikes or drops. This approach is commonly recommended for managing gestational diabetes.

C. Maintain a blood glucose level between 100 to 130 mg/dL before meals.: The target for fasting blood glucose levels in gestational diabetes is generally less than 95 mg/dL. Maintaining blood glucose levels within this range is crucial to manage the condition effectively.

D. Restrict daily carbohydrate intake to 60% of total caloric intake.: Carbohydrate intake should be managed carefully, but it is not typically restricted to a specific percentage like 60%. Instead, a balanced approach with an emphasis on complex carbohydrates and monitoring individual responses is recommended.

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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?

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