A nurse is caring for a client who is visually impaired. When delivering the client's meal tray, which of the following actions should the nurse take?
Describe the food placement as though the plate were a clock.
Provide the client with small-handled adaptive utensils.
Discourage conversations during the client's mealtime.
Arrange for an assistive personnel to feed the client.
The Correct Answer is A
Choice A reason: This is the correct answer because describing the food placement as though the plate were a clock can help the client locate and identify the food items on their tray. For example, the nurse can say, "Your chicken is at 12 o'clock, your mashed potatoes are at 3 o'clock, and your green beans are at 9 o'clock."
Choice B reason: This is not an appropriate action because providing the client with small-handled adaptive utensils can make it harder for them to grip and manipulate the utensils and increase their frustration and dependence. The nurse should provide the client with large-handled or weighted adaptive utensils that can improve their dexterity and control.
Choice C reason: This is not an appropriate action because discouraging conversations during the client's mealtime can make them feel isolated and depressed and reduce their appetite and enjoyment of food. The nurse should encourage conversations during the client's mealtime and provide social support and stimulation.
Choice D reason: This is not an appropriate action because arranging for an assistive personnel to feed the client can compromise their dignity and autonomy and increase their dependence and helplessness. The nurse should respect the client's preferences and abilities and provide assistance only when necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is an indication of a wound infection because redness around the incision line or erythema is a sign of inflammation that can result from bacterial invasion and proliferation in the wound site. The nurse should inspect the wound site for other signs of infection, such as warmth, swelling, pain, or purulent drainage, and collect wound cultures and administer antibiotics as prescribed.
Choice B reason: This is not an indication of a wound infection because serous wound drainage or clear, watery fluid is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should measure and document the amount and color of wound drainage and change the dressings as prescribed.
Choice C reason: This is not an indication of a wound infection because crusting along the incision or scab formation is a normal finding in the first 3 days after surgery and indicates the initial phase of wound healing. The nurse should avoid removing or picking at the crusts and keep the wound site clean and dry.
Choice D reason: This is not an indication of a wound infection because bruising around the wound or ecchymosis is a normal finding in the first 3 days after surgery and indicates tissue damage or bleeding from the surgical trauma. The nurse should monitor the size and color of the bruise and apply ice packs as prescribed.
Correct Answer is D
Explanation
Choice A reason: This is not a good statement because refined grains are processed carbohydrates that have low nutritional value and high glycemic index, which can increase blood sugar and insulin levels and promote fat storage. The nurse should advise the client to choose whole grains instead, which are rich in fiber, vitamins, minerals, and antioxidants.
Choice B reason: This is not a good statement because rewarding oneself with special foods can undermine the weight loss efforts and create a negative association between food and achievement. The nurse should suggest other ways of rewarding oneself that are not food-related, such as buying new clothes, going to the movies, or getting a massage.
Choice C reason: This is not a good statement because planning meals so up to 40 percent of calories come from fats can exceed the recommended intake of fats, which is 20 to 35 percent of total calories. The nurse should also emphasize the importance of choosing healthy fats, such as monounsaturated and polyunsaturated fats, over saturated and trans fats, which can increase the risk of cardiovascular disease.
Choice D reason: This is a good statement because consuming 500 fewer calories per day than the estimated calorie needs can create a moderate energy deficit that can lead to a gradual and sustainable weight loss of about one pound per week. The nurse should also encourage the client to increase physical activity to burn more calories and preserve lean muscle mass.
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