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 immunization that the nurse should identify as needed for this client because measles, mumps, and rubella are viral diseases that can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice B reason: This is not an immunization that the nurse should identify as needed for this client because human papilloma virus is a sexually transmitted infection that can cause genital warts or cervical cancer and can be prevented by vaccination before sexual activity or exposure. The nurse should educate the client about safe sex practices and screening tests for cervical cancer.
Choice C reason: This is not an immunization that the nurse should identify as needed for this client because inactivated polio virus is a vaccine that protects against poliomyelitis, a viral disease that can cause paralysis or death and can be prevented by vaccination in childhood or early adulthood. The nurse should ask the client about their vaccination history and check their immunity status by blood tests if necessary.
Choice D reason: This is an immunization that the nurse should identify as needed for this client because herpes zoster is a viral disease that causes shingles, a painful rash with blisters that can affect any part of the body and can be prevented by vaccination in older adults. The nurse should recommend that the client receive two doses of herpes zoster vaccine at least 2 months apart.
Correct Answer is B
Explanation
Choice A reason: This is not an appropriate action because performing hand hygiene with hands at elbow level can contaminate or recontaminate hands by allowing water or soap to drip from elbows to hands or wrists. The nurse should perform hand hygiene with hands lower than elbows and avoid touching faucets or sinks with hands or forearms.
Choice B reason: This is an appropriate action because cleaning a blood spill with chlorine bleach can disinfect and decontaminate surfaces that have been exposed to bloodborne pathogens, such as hepatitis B virus or human immunodeficiency virus. The nurse should wear gloves and use a 1:10 dilution of bleach and water to clean the spill.
Choice C reason: This is not an appropriate action because instructing a female client to wipe her perineal area from back to front can increase the risk of urinary tract infection or vaginal infection by introducing bacteria from the anus to the urethra or vagina. The nurse should instruct the client to wipe her perineal area from front to back and use a clean tissue for each wipe.
Choice D reason: This is not an appropriate action because rolling soiled linen with clean side in before placing it in laundry bag can spread microorganisms or body fluids to hands, clothing, or environment. The nurse should fold or roll soiled linen with dirty side in and avoid shaking or tossing it.
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