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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Related Questions
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect. Losing bladder control is not a feature of complex partial seizures, but rather of generalized tonic-clonic seizures. Complex partial seizures are a type of focal seizures that affect a specific area of the brain and cause impaired awareness and automatisms. Automatisms are repetitive and involuntary movements or behaviors that occur during a seizure.
Choice B Reason: This choice is incorrect. Having fixed and dilated eyes is not a feature of complex partial seizures, but rather of brain death or severe brain injury. Complex partial seizures do not affect the pupils or eye movements, but rather the level of consciousness and motor activity.
Choice C Reason: This choice is incorrect. Making involuntary groaning sounds is not a feature of complex partial seizures, but rather of simple partial seizures. Simple partial seizures are a type of focal seizures that affect a specific area of the brain and do not impair awareness or cause automatisms. They can cause sensory, motor, or psychic symptoms, such as auditory or visual hallucinations, tingling sensations, or emotional changes.
Choice D Reason: This is the correct choice. Having involuntary facial movements, such as lip-smacking, is a feature of complex partial seizures. Complex partial seizures often originate from the temporal lobe of the brain, which is involved in memory, language, and emotion. They can cause automatisms that affect the mouth, face, or hands, such as chewing, swallowing, picking, or fidgeting.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because acute hemorrhagic stroke is not consistent with these observations. Acute hemorrhagic stroke is a sudden bleeding in the brain that can cause severe neurological deficits, such as paralysis, aphasia, or coma. It does not cause tremors, slowness, or mask-like facial expressions.
Choice B reason: This is incorrect because Alzheimer's disease is not consistent with these observations. Alzheimer's disease is a progressive degeneration of the brain that causes cognitive impairment, memory loss, and behavioral changes. It does not cause tremors, slowness, or mask-like facial expressions.
Choice C reason: This is the correct answer because Parkinson's disease is consistent with these observations. Parkinson's disease is a chronic disorder of the brain that affects movement and coordination. It causes tremors, slowness, rigidity, and postural instability, as well as mask-like facial expressions due to reduced facial muscle activity.
Choice D reason: This is incorrect because traumatic brain injury is not consistent with these observations. Traumatic brain injury is damage to the brain caused by external force, such as a blow, fall, or penetration. It can cause various neurological symptoms depending on the location and severity of the injury, but it does not typically cause tremors, slowness, or mask-like facial expressions.
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