An older client is admitted to the medical-surgical unit after falling and fracturing the left hip. The nurse is reviewing written preoperative instructions with the client and spouse. Which action should the nurse implement while providing these instructions?
Turn the overhead lights on while giving instructions.
Stand behind the client to avoid intimidation.
Provide handouts written at a 12th grade reading level.
Use background music to promote relaxation.
The Correct Answer is A
Rationale:
A. Turning on overhead lights ensures that the client can see the instructions clearly, which is particularly important for older adults who may have visual impairments. Adequate lighting helps improve comprehension and reduces the risk of misunderstandings.
B. Standing behind the client may cause confusion or discomfort. It is better to face the client while communicating.
C. Handouts should be written at a lower reading level, typically around the 5th to 6th grade, to ensure that most clients can understand them, especially older adults.
D. Background music may be distracting rather than helpful during the provision of important instructions.
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Correct Answer is A
Explanation
Rationale:
A. Dysphagia, or difficulty swallowing, significantly increases the risk of aspiration, especially when consuming a full liquid diet that may not be easily controlled in the mouth. Aspiration can lead to serious complications, such as aspiration pneumonia.
B. Oxygen administration via a face mask does not typically increase the risk of aspiration unless the client has underlying conditions affecting swallowing.
C. Sensory aphasia affects communication but does not directly impact the swallowing mechanism, so it poses less risk of aspiration compared to dysphagia.
D. While clients with a nasogastric tube may be at some risk for aspiration, the risk is lower compared to a client with dysphagia actively consuming liquids.
Correct Answer is C
Explanation
Rationale:
A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.
B. Asking the client to close his eyes is not necessary for assessing muscle strength.
C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.
D. Providing an object to hold is not relevant for assessing muscle strength in this context.