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 D
Explanation
Choice A reason: This is not an appropriate area to check for pallor because the antecubital space, or the inner elbow, is not a reliable indicator of skin color changes due to variations in pigmentation and blood flow.
Choice B reason: This is not an appropriate area to check for pallor because the pinna of the ear, or the outer ear, is not a reliable indicator of skin color changes due to variations in pigmentation and blood flow.
Choice C reason: This is not an appropriate area to check for pallor because the abdomen is not a reliable indicator of skin color changes due to variations in pigmentation and fat distribution.
Choice D reason: This is an appropriate area to check for pallor because the conjunctiva, or the inner lining of the eyelid, is a reliable indicator of skin color changes due to its consistent pink color in healthy individuals regardless of race or ethnicity. Pallor of the conjunctiva can indicate anemia or shock.
Correct Answer is B
Explanation
Choice A reason: This is not an adverse effect of furosemide, but a possible sign of anxiety, delirium, or drug toxicity from other medications. The nurse should assess the client's mental status and review their medication list for potential interactions or overdoses.
Choice B reason: This is an adverse effect of furosemide, also known as tinnitus, which is a ringing or buzzing sound in one or both ears that can indicate ototoxicity, or damage to the inner ear. The nurse should instruct the client to report this symptom immediately and have their hearing checked regularly.
Choice C reason: This is not an adverse effect of furosemide, but a possible side effect of some antibiotics, such as metronidazole or clarithromycin, that can alter the sense of taste. The nurse should advise the client to maintain good oral hygiene and use sugar-free candies or gum to mask the metallic taste.
Choice D reason: This is not an adverse effect of furosemide, but a possible symptom of allergic rhinitis, or inflammation of the nasal passages due to exposure to allergens, such as pollen, dust, or animal dander. The nurse should ask the client about their history of allergies and recommend antihistamines or nasal sprays as needed.
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