Nursing Elites

1. What nursing intervention is best to improve communication with a hearingimpaired client?

• A. Talk in a regular voice in the good ear
• B. Talk loudly in the impaired ear
• C. Write down the message
• D. Speak slowly and clearly while facing the client

Correct answer: D

Rationale:

2. What is the best intervention to reduce the risk of falling in the hospital room for a blind client being cared for?

• A. Tell the client’s family that they will be expected to stay overnight
• B. Apply restraints to the client
• C. Shout to the client
• D. Orient the client to the location of objects in the room

Correct answer: D

Rationale: The best intervention to reduce the risk of falling in the hospital room for a blind client is to orient the client to the location of objects in the room. This helps the client navigate safely and independently. Choices A, B, and C are incorrect because telling the client's family to stay overnight, applying restraints, and shouting are not appropriate interventions for preventing falls in a blind client; in fact, they could potentially lead to increased anxiety and risk of falls.

3. Which of the following statements by a client with human immunodeficiency virus (HIV) does NOT requires further teaching?

• A. I can spread this through contact with surfaces, so I need to wear gloves in public.'
• B. Because I have HIV, that means I'm an AIDS patient'
• C. I need to ensure that I place my needles in a proper needle disposal container.'
• D. I can still have unprotected intercourse with my partner since he does not have HIV.'

Correct answer: C

Rationale:

4. A client does not understand why vision loss due to glaucoma is irreversible. What is the nurse's best explanation?

• A. Once retinal detachment occurs, it does not return to its normal state
• B. Once the tissue has necrosed from high-pressure, it does not regenerate
• C. Glaucoma always leads to permanent blindness
• D. Once bacterial infection has caused damage, the tissue does not regenerate

Correct answer: B

Rationale: The correct explanation for irreversible vision loss in glaucoma is that once the tissue has necrosed from high pressure, it does not regenerate. This necrosis occurs due to the damage caused by increased intraocular pressure, which leads to irreversible damage to the optic nerve and retinal tissue. Choices A, C, and D are incorrect because they do not directly address the specific mechanism of irreversible vision loss in glaucoma, which is necrosis due to high pressure.

5. What is the priority nursing diagnosis for a client with immobility?

• A. Constipation related to immobility
• B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
• C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
• D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.

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