A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Ask the client if she would prefer a liquid diet.

Assign an assistive personnel to feed the client.

Explain to the client that her tray is here and place her hands on it.

Describe to the client the location of the food on the tray.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.

Choice B rationale

Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.

Choice C rationale

Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.

Choice D rationale

Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.

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Correct Answer is C

Explanation

Choice A rationale

Pitting edema of the hands and fingers is not a typical finding in clients with systemic lupus erythematosus (SLE). Edema can occur in SLE, but it is more commonly associated with renal involvement and not specifically pitting edema of the hands and fingers.

Choice B rationale

Subcutaneous nodules on the ulnar side of the arm are more commonly associated with rheumatoid arthritis rather than SLE. SLE does not typically present with subcutaneous nodules.

Choice C rationale

A dry, red rash across the bridge of the nose and on the cheeks, known as a “butterfly rash,” is a classic sign of SLE. This rash is caused by inflammation of the small blood vessels in the skin and is often exacerbated by sun exposure.

Choice D rationale

A grey-colored, non-purpuric papular rash is not characteristic of SLE. The typical rash in SLE is the butterfly rash, which is dry, red, and raised.

A. Erythema and edema of the affected ear. B. Pain when manipulating the affected ear lobe. C. Tugging on the affected ear lobe. D. Clear drainage from the affected ear.

Correct Answer is C

Explanation

Choice A rationale

Erythema and edema of the affected ear are more commonly associated with external otitis (swimmer’s ear) rather than otitis media. Otitis media involves the middle ear, not the external ear canal.

Choice B rationale

Pain when manipulating the affected ear lobe is also indicative of external otitis. In otitis media, the pain is usually deeper and not affected by manipulation of the ear lobe.

Choice C rationale

Tugging on the affected ear lobe is a common sign in toddlers with otitis media. This behavior is due to the discomfort and pressure in the middle ear caused by the infection.

Choice D rationale

Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum.

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A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A clinic nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A nurse is caring for a toddler who has otitis media. Which of the following assessment findings should the nurse expect?

Correct Answer is C

Explanation

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A nurse is caring for a client who has bilateral eye patches in place following an injury.
When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?