A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

The nursing assistant is speaking in a normal tone

The nursing assistant is facing the client while speaking

The nursing assistant is speaking directly into the impaired ear

The nursing assistant is speaking clearly to the client

Answer and Explanation

Correct Answer : A,B,D

Choice A reason: The nursing assistant is speaking in a normal tone is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking in a normal tone can help the client to hear the natural variations and inﬂections of the voice, and to avoid distortion or confusion. Speaking in a high-pitched or

low-pitched tone can make the voice harder to hear or understand, especially if the client has a hearing loss in a specific frequency range. Therefore, this choice is correct.

Choice B reason: The nursing assistant is facing the client while speaking is an action that the PN should not intervene in during communication with the client who is hearing impaired. Facing the client while speaking can help the client to see the facial expressions and lip movements of the speaker, and to enhance visual cues and feedback. Facing away from the client while speaking can make the voice muﬄed or unclear, and can interfere with eye contact or rapport. Therefore, this choice is correct.

Choice C reason: The nursing assistant is speaking directly into the impaired ear is an action that the PN should intervene in during communication with the client who is hearing impaired. Speaking directly into the impaired ear can create an uncomfortable or unnatural position for the client and the speaker, and interfere with eye contact or facial expressions. Speaking directly into the impaired ear can also create a loud or distorted sound that may be unpleasant or painful for the client. Speaking face-to-face, and slightly toward the unaﬀected ear, can improve communication with a client who is hearing impaired. Therefore, this choice is incorrect.

Choice D reason: The nursing assistant is speaking clearly to the client is an action that the PN should not intervene in during communication with the client who is hearing impaired. Speaking clearly to the client can help the client to hear and understand the words and sentences of the speaker, and to avoid miscommunication or misunderstanding. Speaking unclearly to the client can make the voice garbled or incomprehensible, and can cause frustration or confusion. Therefore, this choice is correct.

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Correct Answer is ["B"]

Explanation

Choice A reason: Maslow’s hierarchy of needs is a framework for prioritizing human needs, but it is not an organized approach for performing a physical examination. A physical examination should be systematic and comprehensive, not based on subjective preferences or assumptions. Therefore, this choice is incorrect.

Choice B reason: A head-to-toe assessment is an organized approach for performing a physical examination that covers all the major body systems and regions. It allows the nurse to identify any abnormalities or changes in the client’s health status and to document the findings in a consistent manner. Therefore, this choice is correct.

Choice C reason: Subjective data collection is the process of obtaining information from the client about their symptoms, feelings, beliefs, and preferences. It is an important part of the nursing assessment, but it is not an organized approach for performing a physical examination. A physical examination requires objective data collection, which involves observing, measuring, and testing the client’s physical signs. Therefore, this choice is incorrect.

Choice D reason: Review of systems is an organized approach for performing a physical examination that focuses on each body system separately and asks specific questions related to its function and problems. It helps the nurse to elicit relevant information from the client and to detect any abnormalities or deviations from normal. Therefore, this choice is correct.

A. Provide the client with a towel and tell the client the nurse will assist her when he/she is finished administering the tube feeding B. Stop administering the tube feeding and assist the client who spilled coﬀee with changing her wet clothing and C. assess for burns D. Request a replacement tray and assist the client with changing her wet clothing

Correct Answer is ["B"]

Explanation

Choice A reason: This is incorrect because it shows a lack of empathy and priority for the client who spilled coﬀee. The nurse should not delay providing care for a client who may have suﬀered a burn.

Choice B reason: This is correct because it shows that the nurse prioritizes the safety and comfort of the client who spilled coﬀee. The nurse should stop the tube feeding and assess for burns, which can be a serious complication.

Choice C reason: This is incorrect because it does not address the potential burn injury of the client who spilled coﬀee. The nurse should not focus on replacing the tray before assessing for burns.

Choice D reason: This is correct because it shows that the nurse delegates appropriately and ensures that both clients receive timely care. The nurse should stop the tube feeding and request another nurse to assist the client who spilled coﬀee.

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A Practical Nurse (PN) is observing a nursing assistant talking to a client who is hearing impaired. The PN should not intervene if which of the following were performed by the nursing assistant during communication with the client: (Select all that apply)

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Subjective data provided by the client included complaints of intermitent chest pain upon exertion. When performing a complete physical examination, the nurse might use an organized approach such as which of the following? (Select all that apply)

Correct Answer is ["B"]

Explanation

A nurse who is assigned to care for six clients is administering a tube feeding to a client when another client spills breakfast coﬀee on her chest and abdomen. What actions by the nurse are best? (Select all that apply)

Correct Answer is ["B"]

Explanation

The Practical Nurse recognizes the communication technique of receiving information and examining responses to

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