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
The correct answer is b. Respiratory depression.
Choice A: Pupillary dilation This is incorrect. Opioid toxicity typically causes pupillary constriction, often referred to as pinpoint pupils. This is the opposite of pupillary dilation.
Choice B: Respiratory depression This is correct. Opioids can excessively stimulate the part of your brain that regulates breathing, leading to respiratory depression. This is a common and significant symptom of opioid toxicity.
Choice C: Chest pain This is not a typical symptom of opioid toxicity. While chest pain can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Choice D: Diaphoresis This is not a typical symptom of opioid toxicity. While diaphoresis (excessive sweating) can occur in various conditions, it is not specifically associated with opioid toxicity. Therefore, this choice is incorrect.
Correct Answer is A
Explanation
Choice A reason: This is an indication that the medication has been effective because hemoglobin is a protein in red blood cells that carries oxygen throughout the body and epoetin alfa is a medication that stimulates red blood cell production in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of hemoglobin for adults is 12 to 18 g/dL.
Choice B reason: This is not an indication that the medication has been effective because WBC count is a measure of white blood cells that fight infection and epoetin alfa does not affect white blood cell production or function in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of WBC count for adults is 4,500 to 11,000/mm³.
Choice C reason: This is not an indication that the medication has been effective because PT or prothrombin time is a test that measures how long it takes blood to clot and epoetin alfa does not affect blood clotting or coagulation in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of PT for adults is 11 to 13.5 seconds.
Choice D reason: This is not an indication that the medication has been effective because total calcium is a measure of calcium in the blood that is important for bone and muscle health and epoetin alfa does not affect calcium levels or metabolism in clients who have anemia or low hemoglobin levels due to chronic kidney disease, chemotherapy, or surgery. The normal range of total calcium for adults is 8.5 to 10.2 mg/dL.
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