A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Ask the client if she would prefer a liquid diet.

Assign an assistive personnel to feed the client.

Explain to the client that her tray is here and place her hands on it.

Describe to the client the location of the food on the tray.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.

Choice B rationale

Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.

Choice C rationale

Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.

Choice D rationale

Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.

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Correct Answer is D

Explanation

Choice A rationale

This statement is incorrect. While the tubes are designed to allow air to enter the middle ear and prevent fluid buildup, water can still enter through the tubes and potentially cause infections or other complications. Therefore, it is important to take precautions to keep water out of the ears, especially during activities like swimming or bathing.

Choice B rationale

This statement is incorrect. Tympanostomy tubes are not designed to be removed every night. They are small tubes inserted into the eardrum to allow air to enter the middle ear and prevent fluid buildup. They remain in place until they naturally fall out on their own, which typically happens within 6 to 12 months.

Choice C rationale

This statement is incorrect. The tubes do not need to be replaced every 2 years. Tympanostomy tubes usually fall out on their own within 6 to 12 months. If they do not fall out naturally, a healthcare provider may need to remove them. However, routine replacement every 2 years is not necessary.

Choice D rationale

This statement is correct. Tympanostomy tubes are designed to fall out on their own, usually within 6 to 12 months after insertion. This natural process allows the eardrum to heal without the need for additional surgical intervention.

A. “My eye really itches, but I’m trying not to rub it.”. B. “The bright light in this room is really bothering me.”. C. “I’m afraid of falling.”. D. “I need something for the pain in my eye. I can’t stand it.”.

Correct Answer is D

Explanation

Choice A rationale

Itching is a common symptom after cataract surgery, and the client should be reminded not to rub or place pressure on the eyes. This comment does not indicate a serious complication.

Choice B rationale

Sensitivity to bright light is also common after cataract surgery. The client can be advised to wear sunglasses to reduce discomfort. This comment does not indicate a serious complication.

Choice C rationale

Fear of falling is a valid concern, especially if the client has impaired vision or depth perception due to the eye patch. However, this comment does not indicate a serious complication that needs immediate reporting.

Choice D rationale

Severe pain in the eye after cataract surgery can indicate a complication such as increased intraocular pressure, infection, or hemorrhage. This comment should be reported to the provider immediately for further evaluation and intervention.

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A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

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A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?