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 ["C","D","E"]
Explanation
Choice A reason: This is not an expected finding for a client who has cystitis because pruritus or itching is not a common symptom of urinary tract infection or inflammation of the bladder. The nurse should assess for other causes of pruritus, such as skin disorders, allergies, or parasites.
Choice B reason: This is not an expected finding for a client who has cystitis because bradycardia or slow heart rate is not a common symptom of urinary tract infection or inflammation of the bladder. The nurse should assess for other causes of bradycardia, such as medication side effects, cardiac disorders, or electrolyte imbalances.
Choice C reason: This is an expected finding for a client who has cystitis because hematuria or blood in urine is a common symptom of urinary tract infection or inflammation of the bladder. The nurse should collect urine samples for urinalysis and culture and sensitivity tests and administer antibiotics as prescribed.
Choice D reason: This is an expected finding for a client who has cystitis because confusion or altered mental status is a common symptom of urinary tract infection or inflammation of the bladder in older adults. The nurse should monitor the client's level of consciousness and orientation and provide safety measures and education as needed.
Choice E reason: This is an expected finding for a client who has cystitis because dysuria or painful urination is a common symptom of urinary tract infection or inflammation of the bladder. The nurse should encourage oral fluid intake and cranberry juice or supplements and administer analgesics as prescribed.
Correct Answer is D
Explanation
Choice A reason: This is not an appropriate intervention because checking for increased salivation is not relevant for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should check for decreased salivation or dry mouth, which is a common symptom of botulism poisoning.
Choice B reason: This is not an appropriate intervention because administering clindamycin hydrochloride is not effective for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should administer botulism antitoxin as prescribed to neutralize the toxin and prevent further damage.
Choice C reason: This is not an appropriate intervention because placing in contact isolation is not necessary for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should use standard precautions and dispose of any contaminated food properly.
Choice D reason: This is an appropriate intervention because monitoring for muscle paralysis is essential for a client who has botulism poisoning, which is caused by ingestion of food contaminated with Clostridium botulinum toxin that blocks nerve impulses and causes flaccid paralysis. The nurse should assess the client's muscle strength, reflexes, and respiratory function and provide supportive care as needed.
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