A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

Guide the client by walking parallel with them.

Use a loud tone of voice when speaking with the client.

Rearrange client’s bedside table items frequently.

Remove objects from client’s path to the bathroom.

Answer and Explanation

The Correct Answer is D

Choice A reason: Guiding the client by walking parallel is less effective than offering an arm for support, which provides stability and orientation. Parallel walking does not ensure safe navigation for someone with visual impairment, as it lacks physical guidance, making it less appropriate for preventing falls or ensuring safety.
Choice B reason: Using a loud tone of voice assumes hearing impairment, which is not indicated in visual sensory loss. Normal volume with clear enunciation is sufficient, and loud tones may be perceived as disrespectful or startling. This intervention is unnecessary and inappropriate for addressing visual impairment, focusing on an irrelevant sensory issue.
Choice C reason: Rearranging bedside table items frequently disorients a visually impaired client, increasing confusion and fall risk. Consistent placement of items supports independence and safety by allowing the client to rely on memory and touch, making this intervention counterproductive and unsafe for the care plan.
Choice D reason: Removing objects from the path to the bathroom prevents tripping hazards, enhancing safety for a client with reduced visual perception. This intervention reduces fall risk, promotes independent mobility, and aligns with evidence-based practices for visually impaired individuals, making it the most effective and appropriate action.

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Correct Answer is B

Explanation

Choice A reason: Attaching restraints to movable side rails is unsafe, as rail movement can cause injury or loosen restraints. They should be secured to the bed frame, a fixed structure, so this guideline is incorrect and dangerous for restraint protocols.
Choice B reason: Documenting the client’s condition every 15 minutes ensures frequent monitoring for safety, circulation, and skin integrity, per CMS and Joint Commission standards. This prevents complications and supports timely restraint removal, making it the correct guideline.
Choice C reason: Requesting PRN restraint prescriptions is inappropriate, as restraints require specific, time-limited orders based on immediate need. PRN orders lack oversight and risk misuse, so this guideline is incorrect and non-compliant with regulations.
Choice D reason: Applying restraints over clothing can cause discomfort or skin irritation, as direct skin contact with padding is preferred for safety. This guideline is incorrect, as proper application minimizes harm, making it inappropriate for protocols.

A. Conducting routine health screenings for early disease detection. B. Administering vaccinations to prevent infectious diseases. C. Developing a rehabilitation plan for a client post-stroke. D. Educating a community about healthy lifestyle choices.

Correct Answer is C

Explanation

Choice A reason: Routine health screenings are part of secondary prevention, focusing on early detection of diseases before symptoms appear. Tertiary prevention addresses management after diagnosis, so this action is misaligned with the phase, making it incorrect for the workshop content.
Choice B reason: Administering vaccinations is primary prevention, aimed at preventing diseases before they occur. Tertiary prevention involves managing existing conditions, so vaccinations do not fit this phase, making this an incorrect choice for interprofessional care focus.
Choice C reason: Developing a rehabilitation plan post-stroke is tertiary prevention, as it minimizes disability and improves function after a disease event. This collaborative effort involves multiple disciplines (e.g., PT, OT), aligning with interprofessional care goals, making it the correct choice.
Choice D reason: Educating about healthy lifestyles is primary prevention, promoting health to prevent disease onset. Tertiary prevention focuses on managing established conditions, so this action is incorrect for the tertiary phase in interprofessional collaboration.

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A nurse is planning care for a client who has reduced visual sensory perception. Which of the following interventions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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