An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?
Have the client vocalize the instructions provided.
Provide written instructions for eye drop administration.
Speak clearly and face the client for lip reading.
Ensure that someone will stay with the client for 24 hours.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Having the client vocalize the instructions provided ensures that they have understood the information correctly. This method allows the nurse to confirm comprehension and clarify any misunderstandings.
Choice B rationale:
Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions. It is a good supplementary measure but should not be the sole method of communication.
Choice C rationale:
Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments. However, it does not guarantee that the client has understood the instructions.
Choice D rationale:
Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.
Correct Answer is D
Explanation
In this scenario, the client is experiencing difficulty falling asleep at night, fatigue, and daytime sleepiness. These symptoms may indicate that the client's exercise routine is impacting their sleep patterns. By asking the client for a description of their exercise schedule, the nurse can gather important information about the timing, intensity, and duration of the client's exercise regimen.
Exercise has numerous benefits for sleep and overall health, but the timing and intensity of exercise can affect sleep patterns differently for individuals. Vigorous exercise close to bedtime may increase alertness and make it harder for some people to fall asleep.
Therefore, understanding the client's exercise routine will help the nurse assess if the timing or intensity of the exercise is contributing to the sleep issues.
Based on the information gathered, the nurse can provide appropriate guidance. This may include adjusting the timing of exercise to earlier in the day, reducing the intensity of exercise closer to bedtime, or considering other factors that may be contributing to the sleep difficulties, such as caffeine intake, stress, or environmental factors.
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