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 A
Explanation
Choice A rationale
Applying the ointment in a thin line into the conjunctival sac ensures that the medication is properly distributed across the surface of the eye, allowing for effective treatment of the bacterial conjunctivitis.
Choice B rationale
Asking the child to look down before applying the ointment is not necessary and may make the application process more difficult. The focus should be on ensuring the ointment is applied correctly.
Choice C rationale
Using a sterile glove and applicator is not required for applying ophthalmic ointment. Clean hands and proper technique are sufficient to ensure safe and effective application.
Choice D rationale
Wiping from the outer to the inner canthus is incorrect. The correct technique is to wipe from the inner to the outer canthus to prevent the spread of infection.
Correct Answer is C
Explanation
Choice A rationale
Erythema and edema of the affected ear are more commonly associated with external otitis (swimmer’s ear) rather than otitis media. Otitis media involves the middle ear, not the external ear canal.
Choice B rationale
Pain when manipulating the affected ear lobe is also indicative of external otitis. In otitis media, the pain is usually deeper and not affected by manipulation of the ear lobe.
Choice C rationale
Tugging on the affected ear lobe is a common sign in toddlers with otitis media. This behavior is due to the discomfort and pressure in the middle ear caused by the infection.
Choice D rationale
Clear drainage from the affected ear is not typical of otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a ruptured eardrum.