A male client is admitted to the stroke rehabilitation unit and is demonstrating right homonymous hemianopsia. The practical nurse (PN) observes that the client only eats the foods on the left side of the plate and tray. Which is the best action for the PN to use with this client to compensate for the visual field deficit?
Place the food and utensils in the client's left visual field and leave him alone.
Feed the client foods that are on the right side of his visual field.
Remind the client to look all over the tray to view and eat all the foods provided.
Prompt the client to rotate his plate to see foods on the right side of the tray.
The Correct Answer is C
Choice A reason: Placing the food and utensils in the client's left visual field and leaving him alone does not address the underlying issue of the visual field deficit. While it may temporarily solve the problem of the client eating only the food on the left side, it does not encourage the client to adapt to or compensate for the right homonymous hemianopsia. The goal of rehabilitation is to help the client develop strategies to manage their condition independently, and this approach does not foster such skills.
Choice B reason: Feeding the client foods that are on the right side of his visual field is not the most effective approach, as it does not promote the client's independence or help them adapt to their visual field deficit. While it ensures the client consumes the food on the right side, it does not teach the client to compensate for their hemianopsia, which is an essential aspect of their rehabilitation.
Choice C reason: Reminding the client to look all over the tray to view and eat all the foods provided is the best approach. This action helps the client become more aware of their visual field deficit and encourages them to develop the habit of scanning their environment. Teaching the client to consistently look around their entire visual field promotes independence and helps them adapt to daily activities despite their condition. This strategy supports the goal of rehabilitation, which is to enhance the client's ability to manage their visual impairment independently.
Choice D reason: Prompting the client to rotate his plate to see foods on the right side of the tray is a practical solution, but it does not address the broader need for the client to learn to scan their environment. While rotating the plate may temporarily help the client access the food on the right side, it does not encourage the development of compensatory strategies for the visual field deficit. Encouraging the client to look all over the tray is a more effective approach for long-term adaptation and independence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Yellow urine can be a sign of dehydration or other conditions, but it is not typically associated with cholelithiasis. While it is important to monitor urine color, it does not indicate a direct complication of gallstones.
Choice B reason: Restlessness can be caused by various factors, including discomfort or anxiety. However, it is not a specific indicator of a complication related to cholelithiasis. The practical nurse should assess the cause of restlessness, but it does not warrant immediate reporting to the charge nurse in the context of gallstones.
Choice C reason: Persistent nausea can be a symptom of cholelithiasis, especially if the gallstones are causing a blockage in the bile ducts. While nausea should be monitored and managed, it is not the most critical finding that requires immediate reporting to the charge nurse.
Choice D reason: Clay-colored stools are a significant finding that indicates a possible bile duct obstruction. When bile flow is blocked, it can result in pale or clay-colored stools. This is a critical sign that requires immediate attention and reporting to the charge nurse, as it suggests a serious complication that needs prompt intervention.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A reason: Checking mucous membranes can provide information about the client's hydration status. Dry mucous membranes can be a sign of dehydration, which may contribute to decreased urine output. This assessment is important to determine whether the client has adequate fluid balance.
Choice B reason: Ensuring that the catheter tubing is straight is essential to confirm that there are no kinks or obstructions that could be causing the reduced urine flow. Any obstruction in the catheter tubing could lead to a sudden decrease in urine output, and this check helps ensure patency.
Choice C reason: Auscultating lung sounds is crucial to assess for fluid overload or pulmonary complications, which can be associated with renal transplant patients. Abnormal lung sounds could indicate issues that may indirectly affect urine output and overall kidney function.
Choice D reason: Determining the dryness of bed linens helps assess whether the client might have experienced a leakage of urine outside the catheter system. If the bed linens are wet, it could indicate an issue with the catheter or bladder function that needs to be addressed.
Choice E reason: Irrigating the catheter to assess patency is a direct method to determine whether there is any blockage or obstruction in the catheter. This procedure helps ensure that the catheter is functioning correctly and allows for appropriate urine drainage.
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