A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
Rephrase statements the client does not hear.
Determine if the client uses hearing aids.
Speak using his usual tone of voice and directly in front of the client.
Use hand gestures to communicate.
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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Correct Answer is C
Explanation
Choice A rationale
Erythema and edema of the affected ear are more commonly associated with external otitis (swimmer’s ear) rather than otitis media. Otitis media involves the middle ear, not the external ear canal.
Choice B rationale
Pain when manipulating the affected ear lobe is also indicative of external otitis. In otitis media, the pain is usually deeper and not affected by manipulation of the ear lobe.
Choice C rationale
Tugging on the affected ear lobe is a common sign in toddlers with otitis media. This behavior is due to the discomfort and pressure in the middle ear caused by the infection.
Choice D rationale
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum.
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.