which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind
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1. Which nursing intervention is most important for the nurse to implement when caring for an older client who is legally blind?

Correct answer: B

Rationale: The correct answer is to speak to the client each time the nurse enters the room. This intervention is crucial for orienting and reassuring the client, promoting safety, and facilitating communication. Keeping the room well-lit (Choice A) can be helpful but is not as essential as direct verbal communication. Ensuring the client wears glasses (Choice C) may not be feasible or necessary for someone who is legally blind. Providing written instructions in large print (Choice D) is not effective for a client with visual impairments.

2. Following a bout of diarrhea, which foods should be offered to the school-age child?

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

3. A client with chronic obstructive pulmonary disease (COPD) presented with shortness of breath. Oxygen therapy was started at 2 liters/minute via nasal cannula. The arterial blood gases (ABGs) after treatment were pH 7.36, PaO2 52, PaCO2 59, HCO3 33. Which statement describes the most likely cause of the simultaneous increase in both PaO2 and PaCO2?

Correct answer: B

Rationale: Oxygen therapy can reduce the hypoxic drive in COPD patients, leading to increased PaCO2 levels while improving oxygenation (PaO2). In this case, the increase in PaO2 and PaCO2 is due to the reduction of the hypoxic drive by the supplemental oxygen. Choice A is incorrect because hyperventilation would lead to decreased PaCO2. Choice C is incorrect as the ABG values do not indicate respiratory alkalosis. Choice D is incorrect as the ABG values do not support metabolic acidosis.

4. A teenage girl has been placed in a brace for the treatment of scoliosis, the most common skeletal deformity of adolescence. The family asks what they can do to be more supportive. What suggestion from the nurse is the most appropriate?

Correct answer: C

Rationale: The most appropriate suggestion from the nurse is to recommend purchasing clothes to disguise the brace. Adolescents with scoliosis often have body image concerns and wish to fit in with their peers. By providing clothes that help conceal the brace, the family can support the teenage girl's emotional well-being. Choices A, B, and D do not directly address the adolescent's concerns about body image and fitting in, making them less appropriate in this situation.

5. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?

Correct answer: D

Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.

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