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A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

A.

Rephrase statements the client does not hear.

B.

Determine if the client uses hearing aids.

C.

Speak using his usual tone of voice and directly in front of the client.

D.

Use hand gestures to communicate.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Rephrasing statements the client does not hear is helpful but not the priority action. The priority is to determine if the client uses hearing aids to ensure they can hear instructions and communication effectively.

 

Choice B rationale

 

Determining if the client uses hearing aids is the priority action. Ensuring the client has and uses their hearing aids can significantly improve communication and care.

 

Choice C rationale

 

Speaking using the usual tone of voice and directly in front of the client is important but secondary to ensuring the client has their hearing aids.

 

Choice D rationale

 

Using hand gestures to communicate can be helpful but is not the priority action. The primary focus should be on ensuring the client has their hearing aids for optimal hearing.


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View Related questions

Correct Answer is ["B","C","D","F"]

Explanation

Choice A rationale

Increased awareness is not a manifestation of anaphylactic shock. Anaphylactic shock typically causes confusion or loss of consciousness due to decreased blood flow to the brain.

Choice B rationale

Chest pain can occur during anaphylactic shock due to the body’s severe allergic reaction and the strain it places on the cardiovascular system.

Choice C rationale

Dyspnea, or difficulty breathing, is a common manifestation of anaphylactic shock. The airways can become constricted, making it hard to breathe.

Choice D rationale

Angioedema, or swelling of the deeper layers of the skin, often occurs during anaphylactic shock. It can affect the face, throat, and other areas.

Choice E rationale

Hypertension, or high blood pressure, is not a typical manifestation of anaphylactic shock. Anaphylactic shock usually causes hypotension, or low blood pressure.

Choice F rationale

Urticaria, or hives, is a common skin reaction during anaphylactic shock. It presents as red, itchy welts on the skin.

Correct Answer is D

Explanation

Choice A rationale

Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.

Choice B rationale

Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.

Choice C rationale

Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.

Choice D rationale

Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.

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