A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?
Describe the food placement as though the plate were a clock.
Provide the client with small-handled adaptive utensils.
Discourage conversations during the client's mealtime.
Arrange for an assistive personnel to feed the client.
The Correct Answer is A
Choice A reason: This is the correct answer because describing the food placement as though the plate were a clock can help the client locate and identify the food items on their tray. For example, the nurse can say, "Your chicken is at 12 o'clock, your mashed potatoes are at 3 o'clock, and your green beans are at 9 o'clock."
Choice B reason: This is not an appropriate action because providing the client with small-handled adaptive utensils can make it harder for them to grip and manipulate the utensils and increase their frustration and dependence. The nurse should provide the client with large-handled or weighted adaptive utensils that can improve their dexterity and control.
Choice C reason: This is not an appropriate action because discouraging conversations during the client's mealtime can make them feel isolated and depressed and reduce their appetite and enjoyment of food. The nurse should encourage conversations during the client's mealtime and provide social support and stimulation.
Choice D reason: This is not an appropriate action because arranging for an assistive personnel to feed the client can compromise their dignity and autonomy and increase their dependence and helplessness. The nurse should respect the client's preferences and abilities and provide assistance only when necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Hypertension is not a typical symptom of anaphylaxis, which usually causes hypotension due to vasodilation and fluid leakage from the blood vessels.
Choice B reason: Difficulty swallowing is a typical symptom of anaphylaxis, which causes swelling of the throat and tongue due to histamine release and inflammation. This is a sign of airway obstruction, which can be life-threatening in anaphylaxis. The other choices are not specific to anaphylaxis and could be caused by other conditions.
Choice C reason: Bilateral tinnitus is not a typical symptom of anaphylaxis, which usually causes ear pain or itching due to allergic inflammation of the ear canal.
Choice D reason: Petechial rash on the abdomen is not a typical symptom of anaphylaxis, which usually causes urticaria (hives) or angioedema (swelling) on the skin. Petechiae are small red or purple spots caused by bleeding under the skin, which can be a sign of a blood disorder or infection.
Correct Answer is D
Explanation
Choice A reason: This is not a priority finding to report to the provider because right-sided weakness is a common and expected manifestation of a left hemispheric stroke, which affects the motor function of the opposite side of the body. The nurse should assess the client's muscle strength and range of motion and provide physical therapy as prescribed.
Choice B reason: This is not a priority finding to report to the provider because difficulty speaking is a common and expected manifestation of a left hemispheric stroke, which affects the language and speech centers of the brain. The nurse should assess the client's ability to understand and express language and provide speech therapy as prescribed.
Choice C reason: This is not a priority finding to report to the provider because inability to follow directions is a common and expected manifestation of a left hemispheric stroke, which affects the cognitive and logical functions of the brain. The nurse should assess the client's level of consciousness and orientation and provide mental stimulation and education as prescribed.
Choice D reason: This is a priority finding to report to the provider because a change in pupil size can indicate increased intracranial pressure, brain herniation, or cranial nerve damage, which are life-threatening complications of a stroke. The nurse should assess the client's pupil size, shape, and reaction to light and notify the provider immediately.
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