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
The correct answer is b. Respiratory depression.
Choice A: Pupillary dilation This is incorrect. Opioid toxicity typically causes pupillary constriction, often referred to as pinpoint pupils. This is the opposite of pupillary dilation.
Choice B: Respiratory depression This is correct. Opioids can excessively stimulate the part of your brain that regulates breathing, leading to respiratory depression. This is a common and significant symptom of opioid toxicity.
Choice C: Chest pain This is not a typical symptom of opioid toxicity. While chest pain can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Choice D: Diaphoresis This is not a typical symptom of opioid toxicity. While diaphoresis (excessive sweating) can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Correct Answer is B
Explanation
Choice A reason: Taking four nitroglycerin sublingual tablets if having chest pain is an incorrect statement that indicates a lack of understanding of the teaching. Nitroglycerin is a medication that dilates the coronary arteries and relieves angina by improving blood flow to the heart. The client should take one nitroglycerin tablet every 5 minutes for up to three doses if having chest pain. If the pain persists after three doses, the client should call emergency response.
Choice B reason: Notifying emergency response if having sudden jaw pain is a correct statement that indicates an understanding of the teaching. Jaw pain is one of the possible signs of a heart attack, which is a life-threatening condition that occurs when the blood supply to the heart is blocked. Other signs of a heart attack include chest pain, arm pain, shortness of breath, nausea, sweating, or dizziness. The client should seek immediate medical attention if experiencing any of these symptoms.
Choice C reason: Waiting 30 minutes before taking action if having heartburn is an incorrect statement that indicates a lack of understanding of the teaching. Heartburn is a burning sensation in the chest or throat that can be caused by acid reflux, gastritis, or other gastrointestinal disorders. However, heartburn can also mimic or mask angina or a heart attack, especially in women, elderly, or diabetic clients. The client should not ignore or delay seeking help if having chest discomfort that may be related to cardiac problems.
Choice D reason: Having hot, dry, and flushed skin if having a heart attack is an incorrect statement that indicates a lack of understanding of the teaching. Hot, dry, and flushed skin is not a typical sign of a heart attack, but it may indicate fever, dehydration, or allergic reaction. The client should monitor his temperature and hydration status and report any abnormal findings to the provider.
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