A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

Place a sign on the client's door indicating visual impairment.

Provide the client with a brightly colored plate and utensils.

When ambulating with the client, grasp the client's arm above the elbow.

Speak in an elevated tone of voice when providing care.

Answer and Explanation

The Correct Answer is C

A) Place a sign on the client's door indicating visual impairment:
While indicating the client’s visual impairment to staff can be helpful, privacy and dignity should also be considered. Alternative methods to inform the staff without compromising the client's privacy should be used.

B) Provide the client with a brightly colored plate and utensils:
Brightly colored plates and utensils can help clients with partial vision impairment but may not be significantly beneficial for those who are fully visually impaired.

C) When ambulating with the client, grasp the client's arm above the elbow:
Grasping the client's arm above the elbow is an effective way to guide a visually impaired person. This allows the client to follow the nurse's movements more naturally and ensures better support and guidance.

D) Speak in an elevated tone of voice when providing care:
Elevating the tone of voice is unnecessary and may be misinterpreted as condescending. Clear, normal, and respectful communication is essential for all clients, regardless of visual impairment.

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Correct Answer is B

Explanation

A) "You will be allowed to drive yourself home within 6 hours following the procedure."This statement is incorrect. After an esophagogastroduodenoscopy (EGD), the patient is typically sedated, and the sedation can affect their alertness, coordination, and judgment. It is generally recommended that patients arrange for someone else to drive them home. It is unsafe for the patient to drive themselves after sedation, even if they feel alert. The nurse should instruct the client to have someone accompany them to the procedure and drive them home afterward.

B) "You might experience a hoarse voice for several days following the procedure."This statement is correct. A hoarse voice is a common and expected side effect after an esophagogastroduodenoscopy, as the procedure involves passing a flexible tube (endoscope) through the mouth and throat. The endoscope may cause irritation to the vocal cords or the lining of the throat, leading to a hoarse voice that can last for a few days. This is a normal, transient effect and should be explained to the patient in advance so they are not alarmed.

C) "You can have a clear liquid diet for breakfast prior to the procedure."This statement is incorrect. For most procedures like EGD, patients are typically instructed to fast for at least 6 to 8 hours prior to the procedure to ensure the stomach is empty. Having food or liquids before the procedure may increase the risk of aspiration or interfere with the examination. The nurse should educate the client to follow fasting instructions and avoid consuming any food or liquids, including clear liquids, as per the healthcare provider's guidelines.

D) "You should not take any of your routine medications until after the procedure is complete."

This statement is generally incorrect. Many patients are instructed to continue taking routine medications, especially if they are vital for managing chronic conditions, unless otherwise directed by the healthcare provider. In some cases, medications such as anticoagulants, aspirin, or certain blood pressure medications may need to be withheld temporarily before the procedure. However, the nurse should clarify with the healthcare provider which medications the client should stop or continue taking before the procedure. The patient should not withhold medications on their own without proper guidance.

A. "I will offer my child apple juice instead of milk." B. "I should continue to feed my child when he pushes food out with his tongue." C. "I will provide his favorite food as a reward for good behavior." D. "I should increase my child's vitamin A intake by feeding him raw carrot slices."

Correct Answer is B

Explanation

A) "I will offer my child apple juice instead of milk.": Offering apple juice instead of milk is not ideal for a toddler with failure to thrive. Milk is a better source of essential nutrients like calcium and vitamin D, which are important for growth and development. Juice can contribute to empty calories and should be limited.

B) "I should continue to feed my child when he pushes food out with his tongue.": This statement indicates an understanding of the importance of addressing feeding difficulties. In toddlers with Down syndrome, it is common to experience difficulties with feeding and swallowing. Continuing to offer food and using techniques to encourage eating, even when the child initially pushes food out, can help ensure adequate nutritional intake and support growth.

C) "I will provide his favorite food as a reward for good behavior.": Using food as a reward can lead to unhealthy eating habits and an association of food with behavior rather than hunger and nutrition. It’s better to use non-food rewards to encourage positive behavior.

D) "I should increase my child's vitamin A intake by feeding him raw carrot slices.": While vitamin A is important, raw carrots can be difficult for toddlers, especially those with developmental delays or oral-motor difficulties, to chew and swallow. Cooked carrots or other vitamin A-rich foods might be a safer option.

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A nurse is creating a plan of care for a newly admitted client who is visually impaired. Which of the following interventions should the nurse include in the plan?

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