An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

Demonstrate the use of visual scanning during meals to the client and family.

Explain that weight loss will be reversed after the acute phase of the stroke has ended.

Suggest that the family bring foods from home that the client enjoys eating.

Encourage the family to offer to feed the client when she does not eat her entire meal.

Answer and Explanation

The Correct Answer is A

Choice A reason: Demonstrating the use of visual scanning during meals can help the client overcome the difficulty with visual perception, which is a common problem after a CVA. Visual perception is the ability to interpret and process the information received from the eyes. A CVA can damage the parts of the brain that are responsible for visual perception, causing impairments such as hemianopia, neglect, or agnosia. Visual scanning is a technique that involves moving the eyes or the head from side to side to scan the entire visual field and compensate for the missing or distorted information. Visual scanning can help the client see all the food on the tray and eat more adequately.

Choice B reason: Explaining that weight loss will be reversed after the acute phase of the stroke has ended is not a helpful response to the family's concern, as it does not address the current issue of the client's nutritional status. Weight loss is a common complication of CVA, due to factors such as dysphagia, anorexia, depression, or medication side effects. Weight loss can affect the client's recovery, immunity, and quality of life. Weight loss may or may not be reversed after the acute phase of the stroke, depending on the client's condition, treatment, and rehabilitation.

Choice C reason: Suggesting that the family bring foods from home that the client enjoys eating is not a sufficient response to the family's concern, as it does not address the underlying cause of the client's poor intake. The client's difficulty with visual perception may prevent her from seeing or recognizing the food, regardless of whether it is from the hospital or from home. The family should also consider the client's dietary restrictions, allergies, and preferences before bringing any food from home.

Choice D reason: Encouraging the family to offer to feed the client when she does not eat her entire meal is not an appropriate response to the family's concern, as it may undermine the client's autonomy and dignity. The client's difficulty with visual perception may not affect her ability to feed herself, as long as she can see the food and the utensils. The family should respect the client's independence and self-care, and only assist her when necessary. The family should also avoid forcing or coaxing the client to eat more than she wants, as this may cause discomfort or resentment.

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Correct Answer is B

Explanation

Choice A reason: Overall fluid intake should not be limited, but rather increased, for a client with urinary tract calculi. Increasing fluid intake can help flush out the stones and prevent new ones from forming.

Choice B reason: Tea and hot chocolate should be limited, because they contain oxalates, which can increase the risk of calcium oxalate stones, the most common type of urinary tract calculi. Other foods high in oxalates include spinach, rhubarb, nuts, and chocolate.

Choice C reason: Low-sodium soups are not a problem for a client with urinary tract calculi, unless they have other conditions that require sodium restriction, such as hypertension or heart failure. Sodium intake does not directly affect the formation of stones, but it can increase calcium excretion in the urine, which can contribute to calcium oxalate stones.

Choice D reason: Citrus fruit juices are beneficial for a client with urinary tract calculi, because they contain citrate, which can prevent the crystallization of calcium and oxalate in the urine. Citrate can also help dissolve existing stones and prevent new ones from forming.

A. Calculate gestation from last menstrual cycle. B. Continue with surgery as scheduled. C. Perform a bedside pregnancy test. D. Notify the surgical team to cancel the surgery.

Correct Answer is C

Explanation

Choice A reason: Calculating gestation from last menstrual cycle is not a reliable way to determine if the client is pregnant, and it is not an urgent intervention that the nurse should implement immediately. The last menstrual cycle may not reflect the actual date of conception, and it may vary depending on the client's cycle length, ovulation time, and other factors. The nurse should use a more accurate and objective method to confirm or rule out pregnancy, such as a urine or blood test.

Choice B reason: Continuing with surgery as scheduled is not a safe or ethical intervention that the nurse should implement immediately, without verifying the client's pregnancy status. Surgery, especially abdominal surgery, can pose significant risks to the client and the fetus, such as bleeding, infection, anesthesia complications, preterm labor, and miscarriage. The nurse should inform the surgical team about the possibility of pregnancy and obtain the client's informed consent before proceeding with surgery.

Choice C reason: Performing a bedside pregnancy test is the most appropriate and timely intervention that the nurse should implement immediately, given the client's situation. A bedside pregnancy test is a simple and quick way to detect the presence of human chorionic gonadotropin (hCG), a hormone produced by the placenta, in the client's urine. A positive result indicates that the client is pregnant, and a negative result indicates that the client is not pregnant. The nurse should perform the test as soon as possible and report the result to the surgical team and the client.

Choice D reason: Notifying the surgical team to cancel the surgery is not a necessary or prudent intervention that the nurse should implement immediately, without confirming the client's pregnancy status. Canceling the surgery may delay the treatment of the client's acute appendicitis, which can lead to serious complications, such as perforation, abscess, peritonitis, and sepsis. The nurse should first perform a bedside pregnancy test and then discuss the risks and benefits of surgery with the surgical team and the client.

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An older client who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and eats only half of the food on the meal tray. The client's family expresses concern about the client's nutritional status. How should the nurse respond to the family's concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?

Correct Answer is B

Explanation

While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?

Correct Answer is C

Explanation

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