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: Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F) is a significant finding that indicates fever, which can be caused by infection, inflammation, or other conditions. However, this is not the priority finding because fever is usually a secondary response to an underlying problem and can be treated with antipyretics and fluids.

Choice B reason: Heart rate change from 110/min to 68/min is a notable finding that indicates bradycardia, which can be caused by medication, vagal stimulation, hypothermia, or cardiac dysfunction. However, this is not the priority finding because bradycardia may not be symptomatic or life-threatening unless it is accompanied by hypotension, chest pain, or altered mental status.

Choice C reason: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg is the priority finding that indicates hypotension, which can be caused by blood loss, dehydration, shock, or medication. Hypotension can impair tissue perfusion and oxygenation and lead to organ failure and death if not corrected promptly. The nurse should assess the client for signs of shock, such as tachycardia, tachypnea, pallor, diaphoresis, or confusion, and initiate interventions to restore blood pressure and circulation.

Choice D reason: Respiratory rate change from 12/min to 20/min is a minor finding that indicates tachypnea, which can be caused by anxiety, pain, fever, or respiratory distress. However, this is not the priority finding because tachypnea may be a compensatory mechanism to increase oxygen delivery or eliminate carbon dioxide and may not affect gas exchange or acid-base balance unless it is severe or prolonged.

A. Difficulty swallowing B. Diarrhea C. Hyperreflexia D. Muscle weakness

Correct Answer is D

Explanation

Choice A reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because difficulty swallowing or dysphagia is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of difficulty swallowing, such as stroke, esophageal disorders, or dementia.

Choice B reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because diarrhea or frequent loose stools is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of diarrhea, such as infection, food intolerance, or medication side effects.

Choice C reason: This is not an expected finding for a client who has a potassium level of 3.2 mEq/L because hyperreflexia or increased reflexes is not a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should assess for other causes of hyperreflexia, such as hyperthyroidism, spinal cord injury, or anxiety.

Choice D reason: This is an expected finding for a client who has a potassium level of 3.2 mEq/L because muscle weakness or decreased muscle strength is a common symptom of hypokalemia or low potassium levels, which can affect cardiac, neuromuscular, and gastrointestinal function. The nurse should monitor the client's vital signs, electrocardiogram (ECG), and serum potassium levels and administer potassium supplements as prescribed.

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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?

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