The nurse is interviewing a patient who has a hearing impairment. What technique would be most beneficial in communicating with this patient?

Correct Answer: A

Rationale: Correct Answer: A Rationale: 1. Assessing the communication method preferred by the patient is crucial as it allows the nurse to tailor the communication approach to the patient's needs. 2. By understanding the patient's preferred communication method, the nurse can ensure effective and respectful communication. 3. This approach promotes patient-centered care and fosters a positive therapeutic relationship. 4. Avoiding facial expressions and hand gestures (B) can hinder communication and may not align with the patient's preferences. 5. Requesting a sign language interpreter (C) may be necessary for some patients, but assessing the patient's preferred method should be the initial step. 6. Speaking loudly and with exaggerated facial movement (D) can be ineffective and may not be the patient's preferred method of communication.

Correct Answer: C

Rationale: The correct answer is C: Begin with the head. This is the most appropriate action as starting with the head allows the nurse to establish rapport with the infant and assess their level of alertness before progressing further. By starting at the head, the nurse can also observe the infant's facial expressions and interactions with the caregiver, providing valuable information about the infant's overall well-being. Assessing reflexes first (Choice A) may startle the infant, asking the parent to undress the child (Choice B) can be done after the initial assessment, and beginning with the legs (Choice D) does not prioritize the critical areas of observation such as the head and face.

Correct Answer: B

Rationale: Step 1: Administering IV antibiotics is important for treating infections, but in this case, the focus is on addressing the pain associated with the deep wound infection. Step 2: Administering pain relief helps improve the client's comfort and quality of life while the infection is being treated. Step 3: Changing the dressing is essential for wound care but does not directly address the client's pain from the infection. Step 4: Performing a CT scan may be necessary to assess the extent of the infection, but it does not directly provide immediate relief for the client's pain. Summary: Administering pain relief is the most appropriate intervention as it directly addresses the client's symptoms and improves their comfort level during the treatment of the deep wound infection.

Correct Answer: C

Rationale: The correct answer is C because it demonstrates empathy and encourages the woman to share her coping mechanisms. This response acknowledges the woman's experience and allows her to express her feelings. It also opens up a dialogue for the nurse to assess her current coping strategies. Choice A is too general and does not prompt further discussion. Choice B is judgmental and dismissive of the woman's experiences. Choice D disregards the woman's emotional state and fails to address her current needs. Overall, Choice C is the most appropriate as it shows empathy, encourages open communication, and allows for further exploration of the woman's coping methods.

Correct Answer: B

Rationale: The main role of the nursing process in community health care is to provide individualized care frameworks. This involves assessing, diagnosing, planning, implementing, and evaluating care tailored to each patient's unique needs. Nursing interventions are personalized based on the individual's health status, preferences, and community resources. This approach promotes holistic and patient-centered care, leading to better health outcomes. The other choices are incorrect because: A: Implementing standardized treatment plans does not account for individual variations and needs. C: Nurses collaborate with diagnostic physicians but do not solely assist them. D: Establishing clinical guidelines is important but not the primary role of the nursing process in community health care.

Correct Answer: D

Rationale: The correct answer is D. The nursing process consists of Assessment, Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. Assessment involves gathering data about the patient's health status. Diagnosis is the identification of the patient's health problems. Outcome Identification sets goals for resolving these problems. Planning involves developing a care plan. Implementation is the execution of the care plan. Evaluation assesses the effectiveness of the care provided. Choices A, B, and C are incorrect: A: Treatment and client outcome are not individual phases in the nursing process. B: Admission and discharge planning are not standalone phases in the nursing process. C: Expected outcome is not a phase, and assessment is missing from the sequence.

Correct Answer: B

Rationale: The correct answer is B: not pulling to a standing position. In an 11-12-month-old child, the inability to pull to a standing position may indicate developmental dysplasia of the hip (DDH) as it can lead to abnormal hip development. Refusal to walk (A) can be a sign of other musculoskeletal issues but not specific to DDH. Negative Trendelenburg sign (C) refers to weakness in the hip abductors and is not a specific finding for DDH. A negative Ortolani sign (D) indicates the absence of hip dislocation and is not a definitive sign of DDH at this age.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's level of understanding about diabetes management. This is the most important nursing action because it enables the nurse to tailor education and interventions to the patient's specific needs. By assessing the patient's understanding, the nurse can address any misconceptions, provide appropriate education, and promote self-management. Checking blood sugar levels every hour (B) is excessive and not necessary unless indicated. Instructing the patient to avoid all sugar-containing foods (C) is overly restrictive and not evidence-based. Ensuring the patient is compliant with their insulin regimen (D) is important but assessing understanding is crucial for effective diabetes management.

Correct Answer: C

Rationale: The correct answer is C: Monitor for transfusion reactions. When a client receiving a blood transfusion develops chills, it may indicate a transfusion reaction, such as a febrile non-hemolytic reaction. The nurse's first priority is to monitor the client closely for other signs of a reaction, such as fever, rash, or shortness of breath. Stopping the transfusion may be necessary, but monitoring for reactions is crucial to identify and manage any adverse effects promptly. Vital signs should be monitored as part of assessing for reactions. Performing a lumbar puncture is not indicated in this situation and is unrelated to managing a transfusion reaction.