A client who recently suffered a stroke suffers from right-sided homonymous hemianopsia. What is the best action for the nurse to take when caring for the client during mealtime?
Place food trays on the left side of the client.
Place food trays on the right side of the client.
Perform a focused visual exam.
Have the assistive personnel feed all meals to the client.
The Correct Answer is A
Choice A reason: This is the correct answer because right-sided homonymous hemianopsia means that the client has lost vision in the right half of both eyes, so placing food trays on the left side of the client will help them see and access their food better.
Choice B reason: This is incorrect because placing food trays on the right side of the client will make it harder for them to see and reach their food, as they have no vision on that side.
Choice C reason: This is incorrect because performing a focused visual exam is not an appropriate action for the nurse to take during meal time. The nurse should assess the client's vision before or after meals, but not interfere with their eating.
Choice D reason: This is incorrect because having the assistive personnel feed all meals to the client will decrease their independence and dignity, as well as their ability to practice using their unaffected side. The nurse should encourage and assist the client to feed themselves as much as possible, and only provide assistance when needed.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is correct because incorporating foods rich in vitamin C in the diet can help prevent or delay macular degeneration. Vitamin C is an antioxidant that can protect the cells of the macula, which is the central part of the retina that is responsible for sharp and detailed vision, from oxidative stress and damage. The nurse should also advise the client to consume foods rich in other antioxidants, such as vitamin E, zinc, lutein, and zeaxanthin.
Choice B Reason: This is correct because receiving injections into the eye can help treat macular degeneration. Injections are a form of anti-vascular endothelial growth factor (anti-VEGF) therapy, which can block abnormal blood vessel growth and leakage in the macula that can cause vision loss. The nurse should explain to the client how often and how long they need to receive injections and what side effects or complications they may experience.
Choice C Reason: This is incorrect because vision will not be restored after using eye drops for macular degeneration. Eye drops are not a proven or effective treatment for macular degeneration, which is a chronic and progressive condition that causes irreversible vision loss. The nurse should reinforce education by informing the client that eye drops may only provide temporary relief of dryness or irritation, but they will not improve or restore vision.
Choice D Reason: This is correct because vision will become progressively more blurry with macular degeneration. Macular degeneration can cause blurred or distorted central vision, difficulty reading or recognizing faces, or dark spots in the visual field. The nurse should educate the client on how to cope with vision loss and use adaptive devices, such as magnifiers, large-print books, or voice-activated technology.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because portal hypertension means that there is high blood pressure in the portal vein, which carries blood from the digestive organs to the liver. When the liver is damaged by hepatitis, it becomes scarred and obstructs the blood flow, causing increased pressure in the portal vein. This leads to fluid accumulation in the abdomen, called ascites, which causes abdominal swelling.
Choice B reason: This is incorrect because portal hypertension is not caused by the heart overworking but by liver damage. The heart does not pump blood into the portal vein, but into the hepatic artery, which supplies oxygenated blood to the liver.
Choice C reason: This is incorrect because portal hypertension does not develop when cirrhosis begins to resolve, but when it progresses. Cirrhosis is a chronic condition that causes irreversible scarring of the liver tissue, which worsens over time and increases portal hypertension.
Choice D reason: This is incorrect because eating high-sodium foods and a stressful lifestyle do not cause portal hypertension, but they can aggravate it. High-sodium foods can increase fluid retention and worsen ascites, while stress can increase blood pressure and worsen bleeding complications. The nurse should advise the client to limit sodium intake and manage stress levels.
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