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 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.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because it is necessary to remove contact lenses before administering medications. Contact lenses can absorb or interfere with the absorption of eye drops and cause irritation or infection. The nurse should instruct the client to remove contact lenses before applying eye drops and wait at least 15 minutes before reinserting them.
Choice B reason: This is incorrect because administering the medications by touching the tip of the dropper to the sclera of the eye can cause contamination or injury. The sclera is the white part of the eye that covers most of the eyeball. The nurse should instruct the client to avoid touching the tip of the dropper to any part of the eye or eyelid and hold it about 1 cm above the lower eyelid.
Choice C reason: This is correct because administering the medications 5 min apart can prevent dilution or washout of one medication by another. Timolol and pilocarpine are two different types of eye drops that are used to treat open-angle glaucoma, which is a condition that causes increased pressure inside the eye and damage to the optic nerve. Timolol is a beta-blocker that reduces the production of fluid in the eye, and pilocarpine is a cholinergic agent that increases the drainage of fluid from the eye. The nurse should instruct the client to apply one drop of each medication in the affected eye(s) and wait at least 5 minutes between each medication.
Choice D reason: This is incorrect because holding pressure on the conjunctival sac for 2 min following the application of eye drops can reduce systemic absorption and side effects of eye drops. The conjunctival sac is the space between the lower eyelid and the eyeball. The nurse should instruct the client to gently close their eyes after applying eye drops and press their index finger against the inner corner of their eye for 2 minutes. This can block the tear duct that drains fluid from the eye to the nose and prevent it from entering the bloodstream.
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