A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

Stand next to the client when speaking.

Guide the client away from background noise.

Provide a copy of the instructions printed in Braille.

Repeat any phrases that the client misunderstands.

Answer and Explanation

Correct Answer : A,B,D

Choice A Reason: This is a correct choice. Standing next to the client when speaking is an action that the nurse should plan to take, as it helps the client hear better and see the nurse's facial expressions and lip movements. The nurse should also speak clearly and slowly, use simple words and sentences, and avoid covering their mouth.

Choice B Reason: This is a correct choice. Guiding the client away from background noise is an action that the nurse should plan to take, as it reduces distractions and interference with hearing. The nurse should also choose a well-lit and quiet place for communication and turn off any unnecessary devices or appliances.

Choice C Reason: This is an incorrect choice. Providing a copy of the instructions printed in Braille is not an action that the nurse should plan to take, as it is not helpful for clients with hearing loss. Braille is a system of raised dots that represents letters and numbers for people who are blind or visually impaired. The nurse should provide a copy of the instructions printed in large font or use pictures or diagrams to supplement verbal information.

Choice D Reason: This is a correct choice. Repeating any phrases that the client misunderstands is an action that the nurse should plan to take, as it ensures comprehension and clarification of important information. The nurse should also ask open-ended questions, encourage feedback, and summarize key points at the end of the conversation.

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Correct Answer is A

Explanation

Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.

Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.

Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.

Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.

A. The client's bladder becomes distended. B. The client states having a severe headache. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.

Correct Answer is ["A","B","C","D"]

Explanation

Choice A Reason: A distended bladder is one of the most common triggers of autonomic dysreflexia, which is a life-threatening condition that occurs in clients with spinal cord injuries above T-6. The bladder becomes overfilled and stimulates the sympathetic nervous system, causing vasoconstriction and hypertension.

Choice B Reason: A severe headache is one of the most common symptoms of autonomic dysreflexia, caused by the increased blood pressure in the brain. The headache may be accompanied by blurred vision, sweating, flushing, or anxiety.

Choice C Reason: An elevated blood pressure is the hallmark sign of autonomic dysreflexia, which can reach dangerously high levels and cause stroke, seizure, or death. The blood pressure may rise up to 300/160 mmHg or higher.

Choice D Reason: Nasal congestion is another possible trigger of autonomic dysreflexia, as it stimulates the nasal mucosa and activates the sympathetic nervous system. Other potential triggers include bowel impaction, skin irritation, tight clothing, or temperature changes.

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A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

Correct Answer is A

Explanation

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia?

Correct Answer is ["A","B","C","D"]

Explanation

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