A nurse is caring for a client who has sensorineural hearing loss and is helping them choose items for their meal tray. Which of the following techniques should the nurse use to help the client communicate their choices?
State the options loudly in a high-pitched voice.
Ask the client's partner to choose their meal.
Expect extended time for verbal responses.
Ask the client to point to items on a picture menu.
The Correct Answer is D
Rationale:
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.
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Correct Answer is B
Explanation
Rationale:
A. Triglycerides within the normal range do not indicate a need for additional nutrients.
B. A low albumin level of 2.8 g/dL indicates poor protein status and may suggest that the client requires additional protein in their enteral feeding to help with healing and overall nutrition.
C. A creatinine level of 1.1 mg/dL is within normal limits and does not indicate a need for additional nutrients.
D. Alkaline phosphatase at 118 units/L is within the normal range and does not suggest a deficiency requiring additional nutrients.
Correct Answer is ["A","C","D","E"]
Explanation
Rationale:
A. Administering methylergonovine maleate is indicated if the uterus is boggy (atonic), as it helps to contract the uterus and reduce the risk of postpartum hemorrhage.
B. Massaging a firm fundus is not appropriate; instead, the nurse should massage a boggy (soft) fundus to promote uterine contraction.
C. Documenting fundal height is a necessary action to assess uterine involution and ensure it is progressing as expected after delivery.
D. Observing the lochia during palpation of the fundus is important to assess for any abnormal findings, such as heavy bleeding, which could indicate complications.
E. Determining whether the fundus is midline is crucial; a displaced fundus may indicate bladder distention, which can affect uterine contraction.