The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss.
The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father.
Which intervention(s) should the nurse implement? (Select all that apply.).
Include the family in the discharge teaching.
Encourage the client to attend reading classes.
Face the client when speaking.
Speak loudly when teaching.
Provide the daughter with written instructions.
Correct Answer : A,C,E
Choice A rationale:
Including the family in the discharge teaching is essential, especially when dealing with a client who has communication barriers such as hearing loss and illiteracy. Involving the daughter in the teaching process ensures that she is aware of the client's care needs and can provide support at home.
Choice B rationale:
Encouraging the client to attend reading classes is not a practical intervention for an older adult with hearing loss. Reading classes may not address the immediate communication needs of the client, and the client's primary caregiver, in this case, is the daughter who will provide daily care and support.
Choice C rationale:
Facing the client when speaking is a crucial intervention when dealing with someone who has hearing loss. By facing the client, the nurse ensures that the client can see their lips and facial expressions, which can aid in lip-reading and understanding the communication better.
Choice D rationale:
Speaking loudly when teaching is not always the best approach for clients with hearing loss. While it may seem intuitive to speak loudly, it can distort speech and make it more challenging for the client to understand. Clear and slow speech, along with visual cues, is often more effective.
Choice E rationale:
Providing the daughter with written instructions is essential, especially when the client has limited reading skills. Written instructions can serve as a reference guide for the daughter, helping her provide care and support to her father accurately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
According to the Mormon dietary code, also known as the Word of Wisdom, Mormons are prohibited from consuming alcohol, tobacco, coffee, and tea.They are also advised to eat meat sparingly and consume fruits, vegetables, and whole grains. Therefore, the nurse should request the following menu items for this client:
- Orange juiceandapple juice, as they are clear liquids and fruits that are allowed by the Word of Wisdom.
- Chicken broth, as it is a clear liquid and a source of protein that can be consumed in moderation.
- Not hot chocolate, as it contains caffeine, which is a stimulant and a "hot drink" that is forbidden by the Word of Wisdom.
Correct Answer is ["A","B","C","E"]
Explanation
Choice A rationale:
Stopping the heparin infusion immediately is essential when the client's aPTT is significantly elevated (in this case, 120 seconds). A prolonged aPTT indicates a higher risk of bleeding, and discontinuing the heparin infusion is a crucial step in preventing further bleeding.
Choice B rationale:
Administering protamine sulfate is necessary when a client on heparin therapy experiences excessive bleeding or if the aPTT is significantly elevated. Protamine sulfate acts as a heparin antagonist and can reverse the anticoagulant effects of heparin.
Choice C rationale:
Notifying the healthcare provider of the significantly prolonged aPTT is essential because it may indicate a need for adjustments in the heparin dosage or therapy. The provider can determine the appropriate course of action based on the client's clinical condition.
Choice D rationale:
Drawing a prothrombin time (PT) and international normalized ratio (INR) level is not necessary in this situation. PT and INR are more relevant parameters when assessing clients on warfarin therapy, not heparin.
Choice E rationale:
Monitoring the client for signs and symptoms of bleeding is crucial when the aPTT is prolonged, as it indicates a higher risk of bleeding. This action allows for early detection and intervention to prevent complications.
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