A nurse is developing a care plan for a patient with hearing loss. Which of the following interventions is most appropriate to promote effective communication with the patient?
Use written communication or visual aids to supplement verbal instructions.
Speak loudly and directly into the patient's ear
Turn off all background noise and speak to the patient from behind.
Assume the patient can read lips and avoid using sign language or gestures.
The Correct Answer is A
A. Use written communication or visual aids to supplement verbal instructions. Written communication and visual aids are effective ways to enhance understanding and provide clear instructions to a patient with hearing loss.
B. Speak loudly and directly into the patient's ear. Speaking loudly can distort sounds and may make it harder for the patient to understand. Instead, clear and slow speech with normal volume is recommended.
C. Turn off all background noise and speak to the patient from behind. While reducing background noise is beneficial, speaking from behind is ineffective as the patient cannot see the nurse’s facial expressions or read lips.
D. Assume the patient can read lips and avoid using sign language or gestures. Assuming the patient can read lips is not appropriate; gestures or other visual aids should be used to enhance communication.
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Correct Answer is B
Explanation
A. Administer high-calorie diet to prevent weight loss. While adequate nutrition is important, a high-calorie diet is not the primary priority in managing heart failure. Sodium and fluid management are usually more crucial to control fluid overload.
B. Reduce sodium intake to help manage fluid retention. Reducing sodium intake is a priority in heart failure management as it helps prevent fluid retention, which reduces workload on the heart and decreases symptoms of fluid overload.
C. Encourage complete bed rest to reduce cardiac workload. Complete bed rest is not recommended as it can lead to deconditioning and increased risk of blood clots. Activity should be balanced according to the patient’s tolerance.
D. Increase fluid intake to maintain hydration. In heart failure, increasing fluid intake could worsen fluid overload. Fluid restriction may be necessary to prevent excess fluid retention.
Correct Answer is C
Explanation
A. Administering pain medication: Pain management is essential, but in this case, the primary concern is potential airway compromise due to inhalation injury, which should be addressed first.
B. Applying a cool, wet cloth to burned areas: Cooling burned areas can help with pain and reduce burn severity but is not the priority in a case of suspected inhalation injury with airway compromise.
C. Administering high-flow oxygen via a non-rebreather mask: This client is at high risk for respiratory compromise due to inhalation injury; administering high-flow oxygen is the priority to ensure adequate oxygenation.
D. Initiating intravenous fluid resuscitation: Fluid resuscitation is essential for burn patients but is not the immediate priority over addressing potential airway and oxygenation issues.