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A nurse is caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions should the nurse take?

A.

Provide a nonskid mat to reduce plate movement.

B.

Encourage the use of wide grip utensils.

C.

Remind that the client look for food on the left side of the tray.

D.

Encourage the client to use her right hand when feeding herself.

Answer and Explanation

The Correct Answer is C

A. A nonskid mat might be helpful for plate stability, but it does not address the visual deficit related to homonymous hemianopsia.  

 

B. Wide grip utensils are useful for motor difficulties, but the primary issue here is a visual field deficit, not motor impairment.  

 

C. Homonymous hemianopsia results in loss of vision in the same half of the visual field in both eyes. Encouraging the client to turn her head or look for food on the affected side (left side of the tray) can help compensate for the visual loss.  

 

D. While using the right hand may be important after a right-sided stroke, the more pressing issue here is addressing the visual field deficit, not hand preference.


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View Related questions

Correct Answer is B

Explanation

A. Using a thermometer to check the temperature of bath water is important for clients with PVD to prevent burns, indicating that this statement reflects understanding.

B. Wearing stockings with elastic tops is not recommended for clients with PVD as they can restrict blood flow and exacerbate symptoms. This indicates a need for further teaching.

C. The statement about not going barefoot is correct, as it helps prevent injury, which is crucial for clients with PVD.

D. Avoiding crossing legs is a proper action to promote circulation and prevent vascular complications, showing the client’s understanding of their condition.

Correct Answer is D

Explanation

A. The nurse should measure the apical pulse for a full minute (not 30 seconds) before administering digoxin. If the pulse is below 60 beats per minute, the medication should be withheld, making this option incomplete.

B. Digoxin should be withheld if the heart rate is below 60/min, not above 100/min. This statement does not reflect proper nursing protocol.

C. Clients taking digoxin should maintain adequate potassium levels, so advising low potassium intake is incorrect. Foods rich in potassium are encouraged.

D. Monitoring for symptoms such as nausea, vomiting, and yellow vision is essential, as these may indicate digoxin toxicity, making this option correct.

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