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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.
Choice B rationale
Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.
Choice C rationale
Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.
Choice D rationale
Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.
Correct Answer is ["B","E","C"]
Explanation
Choice A rationale
Hyperresonance is a booming sound elicited during percussion, typically heard over hyperinflated lung tissue, such as in emphysema or pneumothorax. In the abdominal assessment, hyperresonance is generally not an expected finding and may indicate gaseous distension.
Choice B rationale
Flatness is a dull, very soft sound with a short duration, usually heard over dense tissues such as bone or muscle. In the abdomen, flatness is not a typical percussion sound and might be elicited over a large tumor or organomegaly.
Choice C rationale
Dullness is a thud-like sound with a medium intensity and duration, typically heard over solid organs such as the liver, spleen, or a distended bladder. In the abdominal assessment, dullness is an expected finding over these organs.
Choice D rationale
Resonance is a hollow sound of moderate duration and low pitch, typically heard over normal lung tissue. Resonance is not an expected percussion sound in the abdominal assessment; tympany and dullness are the predominant sounds.
Choice E rationale
Tympany is a drum-like sound with high pitch and longer duration, commonly heard over air-filled structures such as the stomach and intestines. Tympany is the predominant percussion sound expected over most of the abdomen due to the presence of gas in the gastrointestinal tract.
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