The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence
Which action by the patient indicates successful learning?
a. Asks the nurse to test the temperature of the water before entering the bath.
b. Places colored stickers on faucet handles to indicate temperature.
c. Replaces all lace-up shoes with Velcro straps for ease.
d. Uses a heating pad on a low setting to keep warm.
ANS: B
If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold," or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this population. Asking the nurse to test the water does not promote independence, although it does promote safety. Velcro is easier for a patient with a tactile deficit to manipulate and promotes self-care but not safety.
You might also like to view...
The nurse is caring for a female client who is Asian American. Important aspects to consider when planning care include:
a. expecting the client to verbally express disagreement or lack of understanding. b. being flexible with time schedules. c. expecting the client to make health care decisions. d. liberal use of touch during conversation.
The student nurse is preparing to perform a rapid assessment as the more experienced nurse observes. Which of the following statements by the student nurse indicate that further education is required?
1. "The rapid assessment should last approximately 10 minutes.". 2. "I should perform a rapid assessment for all of my assigned clients at the beginning of the shift to help me prioritize care.". 3. "The rapid assessment will help me establish baseline data about the client.". 4. "After I perform the rapid assessments on the clients I've been assigned, I can go back and get more information during my routine assessments.".
A mother is bringing her 2-month-old son in for his well-child visit. He is due to receive his Diphtheria, Tetanus, and Pertussis vaccine. The nurse is educating the mother on the possible side effects of the vaccine, which include:
1. Pain and swelling in the joints. 2. Irritability, loss of appetite, and seizures. 3. Nausea, vomiting, and abdominal pain. 4. Fever and decreased white blood cell count.
A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion?
1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma