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. An infant has been diagnosed with cradle cap. What is the correct intervention to treat the scalp?

Correct answer: B

Rationale: Cradle cap is a common condition in infants characterized by crusty patches on the scalp. The correct intervention to treat cradle cap is to apply mineral oil. Mineral oil helps soften the crusty patches, making it easier to remove them gently. Alcohol (Choice A) can be too harsh for an infant's sensitive skin and may cause irritation. Calamine (Choice C) is used to relieve itching associated with conditions like chickenpox or insect bites, not for treating cradle cap. A&D ointment (Choice D) is typically used for diaper rash and minor skin irritations, not for cradle cap.

3. The mother of a child who has been diagnosed with varicella asks the nurse when the child can return to school. When is the child no longer contagious?

Correct answer: D

Rationale: The correct answer is D: 'When the lesions are crusted over.' Varicella is no longer contagious once the lesions are dry and crusted. This stage indicates that the active viral shedding has significantly decreased, reducing the risk of transmission. Choice A, 'When the fever dissipates,' is incorrect because the presence of fever does not necessarily correlate with the contagiousness of varicella. Choice B, 'After the incubation period,' is incorrect as the incubation period occurs before the onset of symptoms and is not relevant to determining contagiousness. Choice C, 'When the lesions have healed,' is incorrect as healed lesions can still be contagious if they are not crusted over.

4. Parents of a 6-month-old child, who has just been diagnosed with iron deficiency anemia, ask why it was not diagnosed earlier. What would be the best response by the nurse?

Correct answer: B

Rationale: The best response by the nurse would be choice B: 'This happens when the maternal stores of iron are depleted at about 6 months.' Iron deficiency anemia becomes apparent at about 6 months of age in a full-term infant when the maternal stores of iron are depleted. Choice A is incorrect because it questions the diagnosis provided by the healthcare provider. Choice C is incorrect because iron deficiency anemia in infants is primarily due to insufficient iron intake rather than blood loss. Choice D is incorrect as iron deficiency anemia typically develops gradually due to inadequate iron intake.

5. Which dietary modification is most appropriate for a client with nephrotic syndrome?

Correct answer: D

Rationale: The most appropriate dietary modification for a client with nephrotic syndrome is a low protein, low sodium diet. This diet helps reduce the workload on the kidneys and manage edema, which are common issues in nephrotic syndrome. Choice A, high protein, low sodium, is not recommended because excessive protein intake can further strain the kidneys. Choice B, low protein, high sodium, is inappropriate as high sodium can worsen fluid retention and hypertension. Choice C, high protein, high potassium, is not ideal as high potassium levels can be problematic for individuals with kidney issues.

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