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The nurse is continuing to care for the child.
Exhibits
Select the 3 priority actions that the nurse should take.

Administer Ibuprofen 200 mg PO.

Elevate the affected forearm with pillows.

Place a nonadherent dressing on the right knee abrasion.

Review cast care instructions with the child's parents.

Apply ice packs to the fingers and along the right forearm.

Explain the cast application procedure to the child.

Answer and Explanation

Correct Answer : A,B,E

Rationale:

A. Administer Ibuprofen 200 mg PO: The child reports a pain score of 5/10 and is requesting pain medication. The provider has prescribed ibuprofen PRN for this level of pain. Prompt administration supports comfort and reduces inflammation associated with fracture and swelling.

B. Elevate the affected forearm with pillows: Elevation helps reduce edema by promoting venous return and lymphatic drainage. Given the child's worsening edema in the forearm and fingers, this is a priority to minimize complications like compartment syndrome.

C. Place a nonadherent dressing on the right knee abrasion: Although dressing the abrasion is a reasonable intervention, it is not a priority at this stage. The abrasion is not actively bleeding or infected, so attention should remain on managing neurovascular risk and pain.

D. Review cast care instructions with the child's parents: This is an important educational step, but it is not a current priority since the cast has not yet been applied. Priority actions should focus on pain, swelling, and circulation while awaiting casting.

E. Apply ice packs to the fingers and along the right forearm: Ice helps manage pain and inflammation by vasoconstriction, limiting fluid accumulation in tissues. Applying it early post-injury is crucial to controlling swelling in a fractured limb.

F. Explain the cast application procedure to the child: Preparing the child for a future procedure is helpful but not immediately necessary. At this point, pain control and reduction of swelling take precedence to prevent complications and stabilize the injury.

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Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. C. Touch the client gently to announce presence. D. Approach the client from the side. E. Allow extra time for the client to perform tasks.

Correct Answer is ["A","C","E"]

Explanation

Rationale:

A. Keep objects in the client's room in the same place: Maintaining a consistent environment helps clients with vision loss navigate safely and confidently. Sudden changes in object placement can increase the risk of disorientation and injury.

B. Ensure there is high-wattage lighting in the client's room: While good lighting benefits clients with partial vision, high-wattage lighting can cause glare or discomfort. The focus should be on well-distributed, non-glare lighting suited to individual needs rather than universally high intensity.

C. Touch the client gently to announce presence: Gently touching a visually impaired client before speaking helps avoid startling them and fosters trust. It is a respectful way to make presence known when visual cues are unavailable.

D. Approach the client from the side: Approaching from the front is preferable so the client can better perceive the nurse's presence through remaining visual fields or auditory cues. Side approaches may lead to disorientation or surprise.

E. Allow extra time for the client to perform tasks: Clients with vision loss may require additional time to complete self-care or communication tasks. Rushing them can increase stress and compromise safety, so patience supports their independence.

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The nurse is continuing to care for the child.Exhibits Select the 3 priority actions that the nurse should take.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

Correct Answer is D

Explanation

A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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The nurse is continuing to care for the child.
Exhibits
Select the 3 priority actions that the nurse should take.