A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention for this client?

Place the wheelchair on the client's left side.

Orient the client to the food on the plate using the clock method.

Teach the client to turn scan to the right to see objects on the right side of the body.

Place the bedside table on the right side of the bed.

Answer and Explanation

The Correct Answer is C

Choice A reason:

Placing the wheelchair on the client's left side is not helpful for someone with left homonymous hemianopsia, as the client will have difficulty seeing the left side. This intervention does not address the visual deficit properly.

Choice B reason:

Orienting the client to the food on the plate using the clock method is beneficial for clients with visual impairments, but it is not specific to addressing left homonymous hemianopsia. It does not help the client scan their environment effectively.

Choice C reason:

Teaching the client to turn their head to scan to the right helps compensate for the left-sided visual field loss. This strategy allows the client to detect objects in their blind spot and improves their ability to navigate their environment safely.

Choice D reason:

Placing the bedside table on the right side of the bed ensures it is within the client’s field of vision and easily accessible, which is a supportive measure. However, teaching scanning techniques is more critical in helping the client adjust to their visual deficit.

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Correct Answer is ["B","C","D"]

Explanation

Choice A reason: Grilled chicken is a suitable food choice for clients taking MAOIs. It does not contain significant levels of tyramine and poses no risk of causing hypertensive crises, which can occur when tyramine-rich foods are consumed.

Choice B reason: This is the correct answer. Red wine contains high levels of tyramine, which can interact with MAOIs to cause severe hypertensive crises. Patients on MAOIs are advised to avoid all forms of fermented alcoholic beverages.

Choice C reason: This is the correct answer. Smoked sausage is another food high in tyramine. The fermentation and curing processes increase tyramine content, making it unsafe for patients on MAOIs.

Choice D reason: This is the correct answer. Aged cheddar and other aged cheeses contain high levels of tyramine due to the aging process. Consuming these can lead to dangerous blood pressure elevations in patients taking MAOIs.

Choice E reason: Cereal is typically safe for clients on MAOIs as it generally does not contain tyramine. Regular cereal options are suitable for a diet that needs to avoid tyramine-rich foods.

A. Monitor the Glasgow Coma Scale. B. Complete the Braden Scale. C. Initiate a Brudzinski flow sheet. D. Assess for Babinski's sign.

Correct Answer is B

Explanation

Choice A reason:

Monitoring the Glasgow Coma Scale (GCS) is used to assess a client's level of consciousness, typically in cases of head injury or altered mental status. It is not relevant to the assessment of a pressure injury, which requires evaluating the risk factors and extent of skin damage.

Choice B reason:

Completing the Braden Scale is the appropriate action for assessing a client with a pressure injury. The Braden Scale evaluates risk factors for pressure ulcers, including sensory perception, moisture, activity, mobility, nutrition, and friction/shear. This tool helps in creating an effective care plan to prevent further skin breakdown and manage existing ulcers.

Choice C reason:

Initiating a Brudzinski flow sheet pertains to neurological assessment, specifically testing for signs of meningitis. It is not relevant to the assessment or management of pressure injuries in a paraplegic client.

Choice D reason:

Assessing for Babinski's sign is a neurological test to evaluate corticospinal tract function. While important in a complete neurological examination, it does not address the specific needs related to pressure injury assessment and management.

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A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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