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 A
Explanation
Choice A reason: This is the priority finding because an oral temperature of 39° C (102.2° F) can indicate thyroid storm or thyrotoxic crisis, which is a life-threatening complication of hyperthyroidism that causes severe hypermetabolism and organ dysfunction. The nurse should monitor the client's vital signs, administer antithyroid medications and beta blockers as prescribed, and provide cooling measures and supportive care.
Choice B reason: This is not a priority finding because a serum calcium level of 9.2 mg/dL is within the normal range of 8.5 to 10.2 mg/dL and does not indicate hypocalcemia or low calcium levels, which is a potential complication of total thyroidectomy due to accidental removal or damage of the parathyroid glands that regulate calcium metabolism. The nurse should monitor the client's serum calcium levels, assess for signs of hypocalcemia such as tingling, muscle spasms, or Chvostek's sign or Trousseau's sign, and administer calcium supplements as prescribed.
Choice C reason: This is not a priority finding because a moderate amount of serosanguineous drainage on dressings is an expected finding in the first 24 hours after surgery and does not indicate hemorrhage or infection, which are potential complications of total thyroidectomy. The nurse should inspect the dressings and wound site, measure and document the amount and color of drainage, and change the dressings as prescribed.
Choice D reason: This is not a priority finding because a report of a sore throat is an expected finding in the first 24 hours after surgery and does not indicate laryngeal nerve injury or airway obstruction, which are potential complications of total thyroidectomy. The nurse should assess the client's voice quality, respiratory status, and oxygen saturation, and provide analgesics, ice chips, or lozenges as prescribed.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate treatment option for psoriasis because oil-based ointments can occlude the skin and worsen the inflammation and scaling.
Choice B reason: This is the correct answer because phototherapy, or exposure to ultraviolet light, can help reduce the symptoms of psoriasis by slowing down the growth of skin cells and decreasing the immune response.
Choice C reason: This is not an appropriate treatment option for psoriasis because benzoyl peroxide is used for acne and can irritate and dry out the skin.
Choice D reason: This is not an appropriate treatment option for psoriasis because dermabrasion, or removal of the outer layer of the skin, can cause scarring and infection.
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