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: Log rolling the client and placing adult disposable briefs beneath the client is not a correct intervention, as it can cause displacement or misalignment of the fracture, which can lead to complications, such as delayed healing, nerve damage, or infection. Log rolling is a technique that involves moving the client as a unit, without twisting or bending the spine. Adult disposable briefs are absorbent pads that can be worn to manage urinary incontinence.

Choice B reason: Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.

Choice C reason: Releasing the traction so the client can use a bedpan is not a correct intervention, as it can compromise the fracture reduction and alignment, and cause pain and discomfort to the client. A bedpan is a shallow vessel that can be used to collect urine or feces from the client, by placing it under the client's buttocks. Releasing the traction can also increase the risk of bleeding, swelling, or infection.

Choice D reason: Inserting an indwelling urinary catheter preoperatively is not a necessary intervention, unless the client has urinary retention, obstruction, or infection. An indwelling urinary catheter is a tube that is inserted into the bladder through the urethra, and attached to a drainage bag. An indwelling urinary catheter can pose risks of trauma, infection, or bladder spasms, and should be avoided unless indicated.

A. Whole milk and daily servings of ice cream. B. Citrus fruit and melon with a salt substitute. C. Pasta with herbal butter and no meat sauce. D. Canned vegetables with additional table salt.

Correct Answer is A

Explanation

Choice A reason: Whole milk and ice cream are high in fat, which can trigger the inflammation of the gallbladder (cholecystitis) and the formation of gallstones. The client should avoid foods that are high in fat, such as fried foods, cheese, butter, cream, and fatty meats.

Choice B reason: Citrus fruit and melon with a salt substitute are not a problem for a client with cholecystitis, unless they have other conditions that require dietary modifications, such as diabetes or kidney disease. The client should eat a balanced diet that includes fruits, vegetables, grains, and lean proteins.

Choice C reason: Pasta with herbal butter and no meat sauce is also acceptable for a client with cholecystitis, as long as the butter is used sparingly and the pasta is not cooked with oil or cheese. The client should limit the intake of refined carbohydrates, such as white bread, rice, and sugar, and choose whole grains instead.

Choice D reason: Canned vegetables with additional table salt are not recommended for a client with cholecystitis, because they are high in sodium, which can increase the risk of fluid retention and hypertension. The client should reduce the intake of salt and processed foods, such as canned soups, sauces, and snacks, and use herbs and spices to flavor the food.

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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

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A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?

Correct Answer is B

Explanation

After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?

Correct Answer is A

Explanation

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