A patient has been blind for several years because of complications with diabetes mellitus.
Which should the nurse do to assist this patient with meals?

Explain to the patient where items are located on the plate according to the hours on a clock.

Encourage eating one food at a time according to the preferences of the patient.

Order finger foods that are permitted on the patient's diet.

Feed the patient the prescribed meal.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Explaining the location of food items on the plate using the clock face analogy (e.g., "your meat is at 12 o'clock, your vegetables are at 3 o'clock") provides a consistent and easily understandable spatial reference for a visually impaired patient. This method allows the patient to independently locate and access different food items, promoting autonomy during meals.

Choice B rationale

Encouraging eating one food at a time based on preference does not directly address the challenge of navigating the plate when blind. While respecting preferences is important, it doesn't provide a systematic way for the patient to know where each food item is located.

Choice C rationale

Ordering finger foods might seem helpful, but it limits the variety and nutritional balance of the patient's diet. Not all foods can be easily eaten with fingers, and this approach does not promote independence in eating a regular meal.

Choice D rationale

Feeding the patient completely removes their independence and can be disempowering. The goal is to assist the patient in maintaining as much autonomy as possible, and explaining food placement allows them to eat independently.

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Correct Answer is C

Explanation

Choice A rationale

The side-lying position with the head of bed at 30 degrees does not optimally align the nasal passages with the esophagus, increasing the risk of the NGT entering the trachea. Proper alignment facilitates easier and safer insertion into the stomach.

Choice B rationale

The tripod position is typically used for patients experiencing respiratory distress to maximize lung expansion. It does not provide the necessary head and neck alignment for safe nasogastric tube insertion.

Choice C rationale

Sitting the patient in an upright position, ideally between 45 to 90 degrees, uses gravity to aid the passage of the NGT down the esophagus. This position also allows the patient to cough effectively if the tube inadvertently enters the trachea.

Choice D rationale

Hyperextending the patient's head during NGT insertion can close off the esophagus and open the trachea, significantly increasing the risk of misplacement of the tube into the respiratory tract. The neck should be flexed forward with the chin to the chest during insertion.

A. 1 minute. B. 2 minutes in each quadrant. C. 5 minutes. D. 10 minutes.

Correct Answer is C

Explanation

Choice A rationale

Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.

Choice B rationale

Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.

Choice C rationale

Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.

Choice D rationale

Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.

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A patient has been blind for several years because of complications with diabetes mellitus.Which should the nurse do to assist this patient with meals?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse positions a patient for the insertion of a nasogastric (NGT) tube by:

Correct Answer is C

Explanation

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen.Before reporting this finding as silent bowel sounds, the nurse should listen for at least:

Correct Answer is C

Explanation

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A clinical instructor is reviewing the abdominal assessment with a group of students.She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)

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When assessing a 49-year-old woman who has a nursing diagnosis of imbalanced nutrition, less than body requirements related to dysphagia, which data would the nurse expect to find?

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?

Which of the following nutritional therapies should the nurse expect to include in the plan of care?

A patient has been blind for several years because of complications with diabetes mellitus.
Which should the nurse do to assist this patient with meals?