A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client’s food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
Ask the client if she would prefer a liquid diet.
Assign an assistive personnel to feed the client.
Explain to the client that her tray is here and place her hands on it.
Describe to the client the location of the food on the tray.
The Correct Answer is D
Choice A rationale
Asking the client if she would prefer a liquid diet does not promote independence in eating. It may limit the client’s dietary options and does not address the need for the client to learn how to eat independently with bilateral eye patches.
Choice B rationale
Assigning an assistive personnel to feed the client does not promote independence. It makes the client reliant on others for feeding, which does not help in developing self-feeding skills.
Choice C rationale
Explaining to the client that her tray is here and placing her hands on it is a step towards promoting independence. However, it does not provide enough information for the client to locate and identify the food items on the tray independently.
Choice D rationale
Describing to the client the location of the food on the tray promotes independence by enabling the client to use her sense of touch and memory to locate and consume the food items without assistance.
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Correct Answer is C
Explanation
Choice A rationale
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Choice B rationale
Subcutaneous nodules on the ulnar side of the arm are more commonly associated with rheumatoid arthritis rather than SLE. SLE does not typically present with subcutaneous nodules.
Choice C rationale
A dry, red rash across the bridge of the nose and on the cheeks, known as a “butterfly rash,” is a classic sign of SLE. This rash is caused by inflammation of the small blood vessels in the skin and is often exacerbated by sun exposure.
Choice D rationale
A grey-colored, non-purpuric papular rash is not characteristic of SLE. The typical rash in SLE is the butterfly rash, which is dry, red, and raised.
Correct Answer is C
Explanation
Choice A rationale
White drainage on the eyelids is not a normal finding and should be reported to the surgeon. However, this is not a standard discharge instruction but rather a sign of potential infection.
Choice B rationale
Sleeping on the abdomen is not recommended after cataract surgery as it can increase pressure on the eye and disrupt healing. Patients are usually advised to sleep on their back or the unaffected side.
Choice C rationale
Avoiding lifting anything heavier than 4.5 kg (10 lb) for 1 week is a standard instruction to prevent increased intraocular pressure and ensure proper healing of the surgical site.
Choice D rationale
Bending at the waist to pick up objects can increase intraocular pressure and should be avoided. Patients are advised to bend at the knees instead.