Nokea
An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern?
- A. Encourage the family to offer to feed the client when she does not eat her entire meal.
- B. Suggest that the family bring foods from home that the client enjoys
- C. Explain that weight loss will be reversed after the acute phase of the stroke has ended.
- D. Demonstrate the use of visual scanning during meals to the client and family.
Correct Answer: D
Rationale: Visual scanning techniques help the client become aware of the entire meal tray, improving food intake and addressing the family's concerns.
You may also like to solve these questions
A 70-year-old male client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?
- A. Check the insides and linings of all enclosed shoes before putting the shoes on
- B. Wash the feet with soap and water, then apply a topical antibiotic ointment.
- C. Trim toenails weekly to prevent injury.
- D. Avoid wearing sandals or open-toed shoes.
Correct Answer: A
Rationale: Preventing trauma to the feet is critical for clients with diabetes to avoid complications like infections and ulcers.
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider.
- A. Belching
- B. Amber urine
- C. Yellow sclera
- D. Flatulence
Correct Answer: C
Rationale: Yellow sclera indicates jaundice, which is a sign of bile duct obstruction and requires immediate medical attention.
The patient experiences a headache and is unable to move the left side of his body. The most likely cause is
- A. embolic stroke
- B. cerebral thrombosis
- C. cerebral abscess
- D. moyamoya disease
Correct Answer: A
Rationale: Embolic stroke is a common complication of cyanotic congenital heart disease.
Which drug should not be used to control secondary hypertension in a sexually active adolescent female who uses intermittent birth control?
- A. Beta blockers
- B. Calcium channel blockers
- C. ACE inhibitors
- D. Diuretics
Correct Answer: C
Rationale: ACE inhibitors and angiotensin II receptor blockers are teratogenic and should be avoided in sexually active adolescents using birth control.
A 12-year-old male tries out for a middle school hockey team. He has a history of a heart murmur as an infant, but the doctor thought it would go away. During the tryout, he experiences severe dyspnea and becomes light-headed. At your office, he has a normal rhythm, pulse, and blood pressure and is no longer dizzy. There is a grade 4/6 systole ejection murmur that radiates to the neck. There is also an ejection click. An ECG reveals left ventricular hypertrophy. The next approach to his management includes
- A. chest x-ray
- B. exercise test
- C. digitalization
- D. echocardiography
Correct Answer: D
Rationale: Echocardiography is essential to evaluate the severity of aortic stenosis and its effects on the heart.