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
Applying cool compresses can help reduce swelling and discomfort, but it is not the primary instruction for a client scheduled for retinal detachment surgery.
Choice B rationale
Eye drops to constrict the pupils are not typically prescribed for retinal detachment surgery. The focus is on preventing further detachment and ensuring proper healing.
Choice C rationale
Restricting head movement is crucial to prevent further detachment of the retina and to promote proper healing after surgery. The client should be instructed to avoid sudden or excessive head movements.
Choice D rationale
Keeping both eyes patched is not necessary and may cause unnecessary discomfort and disorientation for the client.
Correct Answer is D
Explanation
Choice A rationale
Speaking loudly and into the client’s good ear is not recommended. Loud speech can be distorted and uncomfortable for individuals with presbycusis.
Choice B rationale
Using sign language is not necessary unless the client is proficient in it. Most clients with presbycusis benefit more from clear verbal communication.
Choice C rationale
Sitting by the client’s side and speaking very slowly is not as effective as speaking directly to the client in a normal, clear voice.
Choice D rationale
Speaking directly to the client in a normal, clear voice is recommended. This ensures that the client can read lips and understand the conversation better.