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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A reason: Symptoms are subjective data that are reported by the client, such as pain, nausea, or fatigue. They are not observable or measurable by the nurse, and they may vary depending on the client’s perception or expression. The data that the PN discovered are not symptoms, but objective data that are observed or measured by the nurse, such as skin condition, oral mucus membranes, and temperature. Therefore, this choice is incorrect.
Choice B reason: Urinary retention is a condition in which the client is unable to empty the bladder completely or at all. It can cause symptoms such as difficulty or pain in urinating, frequent or urgent urination, or abdominal distension. It can also lead to complications such as infection, kidney damage, or bladder rupture. The data that the PN discovered are not related to urinary retention, but to dehydration or fever. Therefore, this choice is incorrect.
Choice C reason: Signs of fluid overload are objective data that indicate excess fluid in the body, such as edema, weight gain, crackles in the lungs, or elevated blood pressure. They can result from conditions such as heart failure,
kidney failure, or liver cirrhosis. The data that the PN discovered are not signs of fluid overload, but signs of fluid deficit or heat stroke. Therefore, this choice is incorrect.
Choice D reason: Data clustering is a process of grouping related data together to form a meaningful patern that can support a nursing diagnosis. It can help the nurse to identify the client’s problems, needs, or risks, and to prioritize and plan interventions accordingly. The data that the PN discovered are an example of data clustering, as they represent a patern of signs that indicate a possible problem such as dehydration or fever. Therefore, this choice is correct.
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