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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

Choice A rationale:

Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise1. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.

Choice B rationale:

Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.

Choice C rationale:

Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis1.

Choice D rationale:

Hypokalemia is not a symptom of DKA. In fact, patients with DKA often have high potassium levels in their blood at presentation because acidosis causes potassium to move from inside the cells into the bloodstream1. However, during treatment for DKA, when insulin is administered and acidosis is corrected, potassium moves back into the cells and can lead to low potassium levels or hypokalemia1.

Choice E rationale:

Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.

Choice F rationale:

Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.

A. Crush to increase absorption. B. Store at room temperature. C. Administer with a meal. D. Take before bedtime. E. Take before bedtime.

Correct Answer is D

Explanation

Choice D rationale:

Taking zolpidem before bedtime is the correct information to include in the education. Zolpidem is a medication used for the short-term treatment of insomnia and should be taken immediately before going to bed to facilitate sleep onset.

Choice A rationale:

Crushing zolpidem to increase absorption is not recommended. The medication should be taken whole and not crushed or chewed.

Choice B rationale:

Storing zolpidem at room temperature is correct. Like many medications, zolpidem should be stored at a controlled room temperature, away from moisture and heat.

Choice C rationale:

Administering zolpidem with a meal is not necessary and may delay the onset of its effects. It is typically taken on an empty stomach for faster absorption.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data. Exhibits What are the signs and symptoms of DKA? Select all that apply.

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

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Correct Answer is D

Explanation

The practical nurse (PN) is auscultating a client's lung sounds. Which description should the PN use to document this sound? (Please listen to the audio clip provided). Audio: [Wheezing sound]

Patient Data Exhibits The nurse notes that the client’s oxygen saturation is 88% on room air. What is the priority action by the nurse?

A client with a long history of migraine headaches asks the nurse if there are non-pharmaceutical ways to help obtain pain relief. Which intervention should the nurse offer?

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, “The client reports feeling thirsty and hungry all the time.” How should the nurse label this type of data?

Which information should the practical nurse (PN) collect during the admission assessment of a terminally ill client to an acute care facility?

The nurse is caring for a client who has been admitted with recurring migraine headaches. To assess the quality of the client's pain experienced from the migraine headache, which approach should the nurse use?