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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not an expected sensation during injection of the contrast medium because numbness in the fingertips can indicate peripheral nerve damage or ischemia, which are rare but serious complications of cardiac catheterization. The nurse should assess the client's peripheral pulses, capillary refill, and sensation and report any abnormalities.
Choice B reason: This is not an expected sensation during injection of the contrast medium because pain in the jawline can indicate angina or myocardial infarction, which are rare but serious complications of cardiac catheterization. The nurse should monitor the client's vital signs, electrocardiogram, and chest pain and report any changes.
Choice C reason: This is not an expected sensation during injection of the contrast medium because urge to urinate can indicate bladder distension or urinary tract infection, which are unrelated to cardiac catheterization. The nurse should encourage the client to empty their bladder before the procedure and check for urinary retention or dysuria after the procedure.
Choice D reason: This is an expected sensation during injection of the contrast medium because feeling of heat can occur as a result of vasodilation caused by the contrast medium, which increases blood flow to the skin and mucous membranes. The nurse should inform the client that this sensation is normal and temporary and will subside within a few minutes.
Correct Answer is D
Explanation
Choice A reason: Potassium 4.0 mEq/L is a normal value for serum potassium. Potassium is an electrolyte that regulates nerve and muscle function, cardiac rhythm, and fluid balance. Abnormal levels of potassium can indicate renal dysfunction, dehydration, or acid-base imbalance, but not heart failure.
Choice B reason: Calcium 9.0 mg/dL is a normal value for serum calcium. Calcium is an electrolyte that regulates bone health, muscle contraction, blood clotting, and nerve transmission. Abnormal levels of calcium can indicate parathyroid dysfunction, vitamin D deficiency, or malignancy, but not heart failure.
Choice C reason: Sodium 140 mEq/L is a normal value for serum sodium. Sodium is an electrolyte that regulates fluid balance, blood pressure, and nerve and muscle function. Abnormal levels of sodium can indicate dehydration, fluid overload, or hormonal imbalance, but not heart failure.
Choice D reason: Brain natriuretic peptide (BNP) 275 pg/mL is an elevated value for serum BNP. BNP is a hormone that is released by the heart when it is stretched or stressed due to increased pressure or volume overload. BNP causes diuresis, vasodilation, and decreased blood pressure to reduce the workload of the heart. Elevated levels of BNP indicate heart failure, which means that the heart cannot pump enough blood to meet the body's needs.
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