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 D

Explanation

Choice A rationale

Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.

Choice B rationale

Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.

Choice C rationale

Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.

Choice D rationale

Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.

A. Headaches and blurred vision. B. Tremors and weakness. C. Rash symptoms. D. Painful joints.

Correct Answer is C

Explanation

Choice A rationale

Headaches and blurred vision are not specific to stage I Lyme disease. These symptoms can occur in many other conditions and are not the primary indicators of early Lyme disease.

Choice B rationale

Tremors and weakness are not typical early signs of Lyme disease. These symptoms are more associated with neurological involvement, which occurs in later stages of the disease.

Choice C rationale

Rash symptoms, specifically erythema migrans (a bull’s-eye rash), are the hallmark of stage I Lyme disease. This rash appears at the site of the tick bite and is a key diagnostic feature.

Choice D rationale

Painful joints are more commonly seen in later stages of Lyme disease when the infection has spread and caused more systemic involvement.

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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

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Correct Answer is D

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A client calls the health care clinic and asks the nurse to describe the first signs of Lyme disease. The nurse informs the client to watch for which signs/symptoms of stage I Lyme disease?

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?