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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.
Correct Answer is B
Explanation
Choice A reason: Assigning all staff to the emergency department disrupts care for existing inpatients and may overwhelm ED operations. Staff allocation should follow a triage plan, balancing hospital-wide needs. This action is impractical and risks neglecting other patients, making it less effective than preparing resources.
Choice B reason: Preparing to discharge stable clients frees up beds for incoming casualties, optimizing hospital capacity during a mass casualty event. This aligns with disaster protocols, ensuring resources are available for critical patients. It supports efficient triage and care delivery, making it the correct action.
Choice C reason: Canceling all elective surgeries immediately is premature without assessing the event’s scope. Some surgeries may continue if resources allow, per disaster protocols. This action disrupts hospital operations unnecessarily and is less urgent than preparing beds for casualties, making it inappropriate.
Choice D reason: Requesting ventilators assumes specific needs without assessing the casualty event’s nature. Ventilators may not be immediately required, and resource allocation should follow triage protocols. Preparing beds is a more immediate and versatile action, making this choice less prioritized in the initial response.
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