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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is correct because the lesion on the child's head is most likely a hemangioma, which is a benign tumor of blood vessels that appears as a red or purple mark on the skin. Hemangiomas are common in newborns and usually grow during the first year of life, then shrink and fade over several years. The nurse should reassure the client that hemangiomas are harmless and do not require treatment unless they interfere with vision, breathing, or feeding.
Choice B reason: This is incorrect because the lesion on the child's head will not spread, but rather grow and shrink within a limited area. The nurse should not alarm the client by suggesting that the lesion will spread to other parts of the body or become malignant. The nurse should explain that hemangiomas are not contagious or infectious and do not affect the child's overall health or development.
Choice C reason: This is incorrect because the lesion on the child's head is not caused by scarring from the birth process, but rather by abnormal growth of blood vessels in the skin. The nurse should not confuse or misinform the client about the cause of the lesion. The nurse should explain that hemangiomas are not related to trauma, infection, or genetics, but rather to unknown factors that influence blood vessel formation during fetal development.
Choice D reason: This is incorrect because the lesion on the child's head is not a precancerous lesion and does not need a referral to a dermatologist. The nurse should not scare or mislead the client by suggesting that the lesion is a sign of cancer or requires further evaluation or treatment. The nurse should explain that hemangiomas are benign and usually resolve on their own without any complications or sequelae.
Correct Answer is D
Explanation
Choice A Reason: Head trauma is not one of the top causes of blindness in the United States, but rather a possible cause of it. Head trauma can damage the optic nerve, retina, or brain, leading to vision loss or impairment.
Choice B Reason: Cardiovascular disease is not one of the top causes of blindness in the United States, but rather a risk factor for it. Cardiovascular disease can affect the blood supply and oxygen delivery to the eyes, leading to conditions such as glaucoma, macular degeneration, or retinal vein occlusion.
Choice C Reason: Syphilis is not one of the top causes of blindness in the United States, but rather a rare cause of it. Syphilis is a sexually transmitted infection that can affect the eyes, leading to inflammation, scarring, or detachment of the retina.
Choice D Reason: This is the correct choice. Diabetic retinopathy is one of the top causes of blindness in the United States, affecting about 4.1 million adults. Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina, leading to bleeding, swelling, or leakage of fluid. It can cause blurred vision, floaters, or blindness if left untreated.
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