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 B
Explanation
Choice A: Instructing the client to store the injector at room temperature is not the priority because it is not a life-saving action. Storing the injector at room temperature is important to maintain its effectiveness and prevent damage from heat or cold. However, it is not as urgent as seeking medical attention or recognizing anaphylaxis.
Choice B: Informing the client to seek medical attention following administration of the injection is the priority because it is a life-saving action. Seeking medical attention following administration of the injection is essential to prevent further complications or recurrence of anaphylaxis. Anaphylaxis is a severe allergic reaction that can cause symptoms such as difficulty breathing, swelling, rash, or shock. It can be fatal if not treated promptly and properly. Epinephrine is a medication that can reverse some of the symptoms of anaphylaxis by constricting blood vessels, relaxing airways, and increasing heart rate. However, epinephrine is not a cure for anaphylaxis and its effects may wear off after 15 to 20 minutes. Therefore, the client should seek medical attention as soon as possible after using the injector.
Choice C: Having the client perform a return demonstration of the equipment is not the priority because it is not a life-saving action. Having the client perform a return demonstration of the equipment is important to assess the client's understanding and ability to use the injector correctly. However, it is not as urgent as seeking medical attention or recognizing anaphylaxis.
Choice D: Reviewing the signs of anaphylaxis with the client is not the priority because it is not a life-saving action. Reviewing the signs of anaphylaxis with the client is important to educate the client about how to identify and respond to an allergic reaction. However, it is not as urgent as seeking medical attention or using the injector.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because auscultating the client's abdomen for bowel sounds is an assessment that can provide information about the client's bowel motility and function. The nurse should listen for at least 5 minutes in each quadrant and note the frequency, intensity, and quality of bowel sounds.
Choice B reason: This is not an appropriate action to take first because providing privacy with a set time to defecate is an intervention that can promote regular bowel elimination and prevent constipation. The nurse should perform this action after assessing the client's bowel sounds and other factors that may affect defecation, such as pain, medication, diet, and activity.
Choice C reason: This is not an appropriate action to take first because encouraging oral intake of fluids is an intervention that can soften stool and facilitate bowel movement. The nurse should perform this action after assessing the client's bowel sounds and fluid balance status.
Choice D reason: This is not an appropriate action to take first because administering a fiber-based laxative is an intervention that can increase bulk and stimulate peristalsis. The nurse should perform this action after assessing the client's bowel sounds and contraindications for laxatives, such as bowel obstruction, impaction, or perforation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today