The client with significant visual impairment requires assistance with ADLs.
The nurse provides support when serving food by performing which action?
Ensuring all food is soft.
Serving hot food as quickly as possible.
Describing the food on the tray in terms of the face on the clock.
Leaving the tray on the client's bedside table.
The Correct Answer is C
Choice A rationale
Ensuring all food is soft is an intervention for patients with dysphagia or chewing difficulties, not necessarily for those with visual impairment. While safety is important, restricted textures are only required if a swallowing or dental issue is present. For a visually impaired client, the focus should be on maintaining autonomy and nutritional variety. Unnecessarily altering food consistency can decrease the client's appetite and sense of independence during meals.
Choice B rationale
Serving hot food as quickly as possible is a general standard for food quality but does not address the specific needs of a visually impaired individual. In fact, extremely hot food can be a safety hazard if the client cannot see where the steam or heat is coming from. The priority should be on safe orientation to the tray and providing a clear description of the meal's layout to prevent accidental burns or spills.
Choice C rationale
Describing the location of food items using the numbers on a clock face is a standard and effective rehabilitative technique. This method allows the client to visualize the plate and promotes independence by letting them feed themselves. For example, the nurse might state that the meat is at 6 o'clock and the vegetables are at 2 o'clock. This specific communication strategy enhances the client's spatial awareness and mealtime experience.
Choice D rationale
Leaving the tray on the bedside table without further intervention is negligent for a client with significant visual impairment. Without assistance in identifying the food or its location, the client may be unable to eat, leading to malnutrition or dehydration. Furthermore, it increases the risk of spills and accidents. Proper nursing care involves active engagement to ensure the client is oriented to the environment and can safely consume their meal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8"]
Explanation
Step 1 is 100 mg ÷ 250 mg × 2 mL.
Step 2 is 0.4 × 2 mL.
Step 3 is 0.8. The nurse should administer 0.8 mL.
Correct Answer is C
Explanation
Choice A rationale
Opioids are typically reserved for severe, chronic pain that does not respond to other therapies and are not considered first-line treatment for rheumatoid arthritis. They provide analgesia but do not address the underlying inflammatory processes or provide the anti-inflammatory benefits necessary to manage joint swelling and prevent damage. Furthermore, the risk for dependence and respiratory depression makes them less ideal for initial management.
Choice B rationale
Acetaminophen is an effective analgesic for mild to moderate pain, but it lacks significant anti-inflammatory properties. Because rheumatoid arthritis is a chronic systemic inflammatory disease characterized by synovitis and joint destruction, acetaminophen alone is insufficient for primary treatment. It might be used as an adjunct for pain control, but it cannot replace medications that actively target the inflammatory response occurring within the joints.
Choice C rationale
Nonsteroidal anti-inflammatory drugs are the first-line choice for managing the immediate symptoms of rheumatoid arthritis, such as pain and inflammation. They work by inhibiting cyclooxygenase enzymes, which reduces the production of prostaglandins that mediate the inflammatory response. While they do not slow the progression of the disease like DMARDs, they are essential for providing rapid symptomatic relief during the initial diagnostic and treatment phases.
Choice D rationale
Hormone replacement therapy is used to manage symptoms related to hormonal deficiencies, such as those occurring during menopause, and has no established role as a primary treatment for rheumatoid arthritis. While hormonal shifts can sometimes influence autoimmune conditions, HRT does not provide the analgesic or anti-inflammatory effects required to manage the joint inflammation and pain that characterize a new diagnosis of rheumatoid arthritis.
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