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 correct answer because pneumococcal vaccine can prevent pneumococcal disease, which is caused by bacteria that can infect the lungs, blood, or brain and cause serious complications, especially in older adults. The nurse should recommend that adults aged 65 years or older receive one dose of pneumococcal conjugate vaccine (PCV13) followed by one dose of pneumococcal polysaccharide vaccine (PPSV23) at least one year later.
Choice B reason: This is not an appropriate immunization for this client because HPV vaccine can prevent HPV infection, which can cause genital warts and cervical cancer in women and other cancers in men and women. The nurse should recommend that adolescents aged 11 to 12 years receive two doses of HPV vaccine six to twelve months apart.
Choice C reason: This is not an appropriate immunization for this client because MMR vaccine can prevent measles, mumps, and rubella infections, which are highly contagious viral diseases that can cause serious complications, especially in pregnant women and infants. The nurse should recommend that children receive two doses of MMR vaccine at 12 to 15 months and 4 to 6 years of age.
Choice D reason: This is not an appropriate immunization for this client because tuberculosis vaccine, also known as bacille Calmette-Guérin (BCG) vaccine, can prevent tuberculosis infection, which is caused by bacteria that can affect the lungs and other organs and cause serious complications, especially in people with weakened immune systems. The nurse should recommend that people who live in or travel to countries where tuberculosis is common or who have close contact with someone who has active tuberculosis receive BCG vaccine.
Correct Answer is B
Explanation
Choice A reason: Performing range of motion by adducting the hip is an incorrect instruction for a client who had a total hip arthroplasty. Adduction is moving the leg toward the midline of the body, which can cause dislocation of the prosthesis. The nurse should instruct the client to perform range of motion by abducting (moving away from midline), flexing (bending), and extending (straightening) the hip as prescribed by physical therapy.
Choice B reason: Sitting in a straight-backed chair is a correct instruction for a client who had a total hip arthroplasty. This position helps to maintain proper alignment and stability of the hip joint and prevents excessive flexion or rotation that can cause dislocation. The nurse should also instruct the client to avoid crossing legs, bending forward more than 90 degrees, or twisting at the waist.
Choice C reason: Cleansing the surgical incision with hydrogen peroxide is an incorrect instruction for a client who had a total hip arthroplasty. Hydrogen peroxide is a harsh agent that can damage healthy tissue and delay healing. The nurse should instruct the client to cleanse the incision with mild soap and water or as directed by the provider and keep it dry and covered with sterile dressing.
Choice D reason: Applying moist heat to the incision while in bed is an incorrect instruction for a client who had a total hip arthroplasty. Moist heat can increase swelling, inflammation, and infection risk at the incision site. The nurse should instruct the client to apply ice packs or cold compresses to the incision as needed to reduce pain and swelling.
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