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A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?

A.

Speak loudly and into the client’s good ear.

B.

Use sign language when communicating with the client.

C.

Sit by the client’s side and speak very slowly.

D.

Speak directly to the client in a normal, clear voice.

Answer and Explanation

The Correct Answer is D

Choice A rationale

 

Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.

 

Choice B rationale

 

Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.

 

Choice C rationale

 

Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.

 

Choice D rationale

 

Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.


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Correct Answer is B

Explanation

Choice A rationale

Vision may be temporarily blurred after intraocular lens surgery, but significant vision reduction for 48 hours is not typical and should be reported to a healthcare provider.

Choice B rationale

Restricting lifting objects greater than 10 pounds is crucial to prevent increased intraocular pressure and potential complications after surgery.

Choice C rationale

Aspirin should be avoided as it can increase the risk of bleeding. Alternative pain relief methods should be used.

Choice D rationale

Warm compresses are not recommended as they can increase inflammation and discomfort. Cold compresses may be more appropriate.

Correct Answer is A

Explanation

Choice A rationale

Shutting off the intravenous infusion is the immediate action to take when a client reports difficulty swallowing during infliximab infusion. This could indicate an infusion reaction or anaphylaxis, which requires immediate cessation of the infusion to prevent further complications.

Choice B rationale

Notifying the primary health care provider is important, but the immediate action should be to stop the infusion to prevent further adverse reactions.

Choice C rationale

Having the client take deep breaths and try to relax is not appropriate in this situation, as it does not address the potential infusion reaction or anaphylaxis.

Choice D rationale

Obtaining a prescription for oral diphenhydramine may be part of the treatment for an infusion reaction, but the immediate action should be to stop the infusion. .

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