A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Encourage the use of the wide grip utensils.

Remind the client to look for food on the left side of the tray.

Encourage the client to use his right hand when feeding himself.

Provide a nonskid mat to alleviate plate movement.

Answer and Explanation

The Correct Answer is B

A. Wide grip utensils may help with grasp but do not address visual field deficits.
B. Homonymous hemianopsia involves loss of vision in one half of the visual field; reminding the client to look to the left side of the tray helps them find food in their impaired visual field.
C. Using the right hand is not specifically beneficial for visual field deficits and may not address the issue of homonymous hemianopsia.
D. A nonskid mat helps prevent plate movement but does not address the visual field deficit caused by homonymous hemianopsia.

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Correct Answer is B

Explanation

A. Securing the drain to the client's bed sheet is not an appropriate method for securing the JP drain; it should be secured to the client’s gown or clothing to avoid tension on the drain.

B. Expelling the air from the JP bulb after emptying to re-establish suction is necessary to ensure that the drain continues to function correctly by maintaining negative pressure.

C. Measuring the drainage every hour for the first 8 hr postoperative is more frequent than necessary; monitoring can be done every 4-8 hours depending on the protocol.

D. Removing the JP drain when the drainage has ceased, covering the opening with sterile gauze is incorrect; the drain should be removed per the surgeon’s orders, and the site should be covered with a sterile dressing.

A. "Wear an eye patch on the right eye at all times." B. "Plan to relax in a hot tub spa each day." C. "Engage in a vigorous exercise program." D. "Implement a schedule to include periods of rest."

Correct Answer is D

Explanation

A. "Wear an eye patch on the right eye at all times.": This is not appropriate as wearing an eye patch continuously can cause strain on the other eye. It is generally recommended to alternate the eye patch between eyes to manage diplopia (double vision).
B. "Plan to relax in a hot tub spa each day.": This is inappropriate as heat can exacerbate MS symptoms, leading to increased fatigue and other symptoms.
C. "Engage in a vigorous exercise program.": This is inappropriate because vigorous exercise can cause excessive fatigue in individuals with MS. A moderate, well-balanced exercise program is more beneficial.
D. "Implement a schedule to include periods of rest.": This is appropriate as incorporating periods of rest helps manage fatigue, which is a common symptom in MS. It allows the client to balance activity and rest to avoid exacerbation of symptoms.

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A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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