A nurse is planning to provide discharge teaching for a client who has hearing loss. Which of the following actions should the nurse plan to take?
Dim the lights in the client's room.
Increase the rate of speech when talking with the client.
Answer client's questions using medical terminology.
Face the client while talking.
The Correct Answer is D
Choice A Reason: This is incorrect because dimming the lights in the client's room is not a helpful action for providing discharge teaching for a client who has hearing loss. Dimming the lights can reduce the visibility and clarity of the nurse's facial expressions, gestures, and lip movements, which can aid in communication.
Choice B Reason: This is incorrect because increasing the rate of speech when talking with the client is not an effective action for providing discharge teaching for a client who has hearing loss. Increasing the rate of speech can make it harder for the client to follow and understand what the nurse is saying.
Choice C Reason: This is incorrect because answering client's questions using medical terminology is not an appropriate action for providing discharge teaching for a client who has hearing loss. Medical terminology can be confusing and unfamiliar to the client, which can impair comprehension and learning.
Choice D Reason: This is the correct choice because facing the client while talking is an important action for providing discharge teaching for a client who has hearing loss. Facing the client can enhance eye contact, attention, and rapport. It can also allow the client to see the nurse's facial expressions, gestures, and lip movements, which can facilitate communication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F"]
Explanation
Choice A Reason: Slow even breathing is not a sign of Cushing's Triad, which is a late indicator of increased intracranial pressure (ICP). The breathing pattern may be altered due to brainstem compression, but not necessarily slow or even.
Choice B Reason: This is a correct answer because bradycardia and bounding pulse are part of Cushing's Triad, which reflects an increased vagal tone and decreased cardiac output due to increased ICP.
Choice C Reason: Systolic hypotension with a narrowing pulse pressure is not a sign of Cushing's Triad, which involves an increased systolic blood pressure and a widened pulse pressure due to increased ICP. Hypotension may occur due to shock or hemorrhage, but not as a result of increased ICP.
Choice D Reason: This is a correct answer because irregular respirations are part of Cushing's Triad, which reflects impaired respiratory control due to brainstem compression from increased ICP. The respirations may be Cheyne-Stokes, central neurogenic hyperventilation, apneustic, or ataxic.
Choice E Reason: Tachycardia and bounding pulse are not signs of Cushing's Triad, which involves bradycardia and bounding pulse due to increased ICP. Tachycardia may occur due to pain, anxiety, fever, or hypoxia, but not as a result of increased ICP.
Choice F Reason: This is a correct answer because systolic hypertension with a widening pulse pressure are part of Cushing's Triad, which reflects an increased cerebral perfusion pressure due to increased ICP. The diastolic blood pressure remains stable or decreases, resulting in a widened pulse pressure.
Correct Answer is B
Explanation
Choice A Reason: Measuring the abdominal girth is not related to asterixis, which is a tremor of the hand when the wrist is extended. It may indicate ascites, which is a complication of cirrhosis, but not asterixis.
Choice B Reason: This is the correct choice. Asterixis is a flapping tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings. It is caused by abnormal function of the diencephalic motor centers that regulate the muscles involved in maintaining posture. It is a sign of hepatic encephalopathy, which is a neuropsychiatric disorder that occurs in patients with liver disease.
Choice C Reason: Having the client flex and extend their foot is not related to asterixis, which affects the hand and wrist. It may test for ankle clonus, which is a rhythmic contraction of the calf muscles when the foot is dorsiflexed. It indicates an upper motor neuron lesion, but not hepatic encephalopathy.
Choice D Reason: Asking the client to walk heel to toe is not related to asterixis, which affects the hand and wrist. It may test for balance and coordination, which can be impaired in patients with hepatic encephalopathy, but it is not a specific sign of asterixis.
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