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.
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Related Questions
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate action because positioning the fractured arm below the level of the client's heart can increase swelling, pain, or compartment syndrome in the affected extremity due to impaired venous return and increased pressure within closed spaces. The nurse should position the fractured arm above or at least at level with the client's heart and use a sling or pillow for support.
Choice B reason: This is not an appropriate action because immobilizing the client's fingers using a hand splint can reduce mobility, circulation, or sensation in the affected extremity and increase the risk of contractures, nerve damage, or infection. The nurse should encourage the client to move their fingers and thumb frequently and monitor for any signs of impaired neurovascular status.
Choice C reason: This is not an appropriate action because using a hair dryer to blow hot air into the cast to relieve itching can cause burns, infection, or damage to the skin or cast. The nurse should advise the client to avoid scratching, inserting objects, or applying powders or lotions inside the cast and use cool air, ice packs, or antihistamines as prescribed to relieve itching.
Choice D reason: This is an appropriate action because performing neurovascular checks of the affected extremity every 2 hours can assess the circulation, sensation, and movement of the extremity and detect any signs of impaired neurovascular status, such as pallor, cyanosis, numbness, tingling, or paralysis. The nurse should compare the affected extremity with the unaffected one and report any abnormal findings to the provider.
Correct Answer is B
Explanation
Choice A reason: This is not a correct statement because applying the TENS unit at least 6 inches from the actual site of pain can reduce its effectiveness and cause discomfort or irritation to other areas of the skin. The nurse should instruct the client to apply the electrodes directly over or around the site of pain and follow the provider's instructions regarding placement.
Choice B reason: This is a correct statement because adjusting the TENS unit until feeling a tingling sensation can indicate that it is delivering an adequate amount of electrical stimulation to block pain signals from reaching the brain. The nurse should instruct the client to turn on the TENS unit and increase the intensity gradually until feeling a strong but comfortable tingling sensation.
Choice C reason: This is not a correct statement because charging the TENS unit for 2 hours each day can vary depending on the type and model of the device and its battery life. The nurse should instruct the client to follow the manufacturer's instructions regarding charging and maintenance of the TENS unit and check its power level before each use.
Choice D reason: This is not a correct statement because administering a continuous dose of pain medication is not a function of the TENS unit, which does not deliver any drugs or chemicals into the body. The nurse should instruct the client that the TENS unit works by sending mild electrical impulses through electrodes attached to pads that are placed on the skin.
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