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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason:

Offer oral fluids every 4 hours: This is incorrect because oral fluids should be offered more frequently to maintain hydration. Dehydrated patients need consistent fluid intake to prevent further fluid deficit.

Choice B reason:

Monitor pulse pressure every 6 hours: This is incorrect because pulse pressure monitoring is not a standard intervention for dehydration. Pulse pressure is more relevant for cardiovascular assessments rather than fluid status.

Choice C reason:

Check for neck vein distention: This is correct as it helps assess fluid overload, which can occur with IV fluid replacement. Jugular vein distention is a key indicator of fluid status and potential fluid overload.

Choice D reason:

Limit oral fluids prior to bedtime: This is incorrect as limiting fluids can worsen dehydration. Dehydrated patients need adequate fluid intake throughout the day.

A. "Include refined grains as a good carbohydrate in your diet." B. "Reward yourself with special foods for achieving short-term goals." C. "Plan your meals so up to 40 percent of your calories come from fats." D. "Consume 500 fewer calories per day than your estimated calorie needs."

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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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?

Nursing Test Bank

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Correct Answer is D

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