Which of the ff instructions should be given to the clients family if a client with impaired swallowing has to take solid medication?

Correct Answer: C

Rationale: It is important to instruct the client's family to check with the physician or pharmacist before crushing or breaking tablets, or opening capsules for a client with impaired swallowing who needs to take solid medication. Many medications have special formulations or coating that may alter their effectiveness if not taken whole. Consulting with a healthcare professional ensures that the medication remains safe and effective when modifying its form for a client with difficulty swallowing. Mixing the medication with food (option A) may also alter its effectiveness, so it is crucial to seek guidance before making any changes to the medication form. Using the liquid form of the medication (option B) may be a suitable alternative if available; however, this decision should also be discussed and approved by the healthcare provider. Performing ROM exercises after medication administration (option D) is unrelated to addressing the issue of impaired swallowing and medication administration.

Correct Answer: A

Rationale: In the Snellen eye chart test, the first number (20) represents the distance at which the client is standing from the chart, while the second number (40) represents the distance at which a person with normal vision can read the same line on the chart. A person with 20/40 vision can see letters at 20 feet that a person with normal vision can see at 40 feet. This means that the client's vision is below the standard for normal vision, indicating that they may need corrective lenses to improve their visual acuity.

Correct Answer: D

Rationale: The main purpose of a hearing aid is to improve the patient's ability to hear. Hearing aids are devices designed to amplify sound for individuals with hearing loss or difficulty hearing. They do not amplify background noise or musical sounds specifically; instead, they are meant to enhance the overall perception of sounds to help individuals better understand speech and communicate effectively. Moreover, hearing aids do not occlude the ear, but rather are used to transmit sound into the ear canal to make sounds louder and clearer for the wearer.

Correct Answer: A

Rationale: The client's serum glucose level of 618mg/dl is indicative of severe hyperglycemia, likely due to uncontrolled diabetes mellitus. The client's presentation with hot dry skin, elevated heart rate, and low blood pressure suggests dehydration as a result of osmotic diuresis, which occurs in an attempt to excrete excess glucose. With an elevated heart rate and low blood pressure, it is essential to address the deficient volume to prevent further complications such as hypovolemic shock. Rehydration and fluid replacement are crucial interventions to help restore the client's fluid balance and prevent hemodynamic instability. Addressing the deficient volume related to osmotic diuresis should take the highest priority in this case.

Correct Answer: A

Rationale: A client with a low serum calcium level (hypocalcemia) is at risk for exhibiting Trousseau's sign. Trousseau's sign is a clinical manifestation of hypocalcemia characterized by carpal spasm induced by inflating a blood pressure cuff on the arm above the systolic pressure for a few minutes. This spasm occurs due to the increased neuromuscular irritability caused by low calcium levels. Therefore, a nurse assessing a client with a serum calcium level of 7.2mg/dl should expect to assess Trousseau's sign.