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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.
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.
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