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 C
Explanation
Rationale:
A. Reporting suspected child maltreatment is a legal and ethical responsibility of the nurse; this action is appropriate and does not require intervention.
B. Notifying the health department about a client's diagnosis of chlamydia is a legal requirement, as it is a reportable disease, so this action is appropriate.
C. Sharing a client’s diagnosis with a hospital chaplain without the client's consent could violate the client's confidentiality and requires intervention.
D. Informing the provider about a client's suicide plan is a critical action for patient safety and does not require intervention.
Correct Answer is C
Explanation
Rationale:
A. Compensated metabolic acidosis would show a normal pH with a decrease in HCO3- and a decrease in PaCO2.
B. Compensated respiratory acidosis would show a normal pH with an elevated PaCO2 and a compensatory increase in HCO3-.
C. The low pH indicates acidosis, and the elevated PaCO2 suggests that it is respiratory in origin, with the HCO3- remaining normal, indicating no compensation has occurred yet.
D. Uncompensated metabolic acidosis would present with a low pH, low HCO3-, and normal PaCO2.