Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting with the food tray for a client who is partially blind following a left-sided stroke.
Which of the following nursing interventions promotes client independence?
A. Explain that the tray is here and place the client's hands on the tray.
Explaining that the tray is here and placing the client’s hands on the tray is a supportive action but does not promote independence. It may help the client initially find the tray, but it doesn’t guide them in understanding where each item of food is located, which is essential for independent feeding.
B. Assign an assistive personnel to feed the client.
Assigning assistive personnel to feed the client would provide support but would not promote independence. It could lead to increased dependence on others for feeding and may reduce the client’s motivation to perform self-feeding.
C. Ask the client if she would prefer a liquid diet.
Asking the client if they would prefer a liquid diet is an important consideration for clients with swallowing difficulties, which can be a complication of a stroke. However, this does not directly promote independence in feeding if the client is capable of eating solid foods.
D. Describe to the client the location of the food on the tray.
Describing the location of the food on the tray helps the client understand where each item is placed, akin to a clock face orientation. This empowers the client to feed themselves independently, which is crucial for self-esteem and rehabilitation progress.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom T1 PM Summer 2023 Proctored Exam 5. Take the full exam now
Full Explanation
The correct answer is D.
Choice A reason: Explaining that the tray is here and placing the client’s hands on the tray is a supportive action but does not promote independence. It may help the client initially find the tray, but it doesn’t guide them in understanding where each item of food is located, which is essential for independent feeding.
Choice B reason: Assigning assistive personnel to feed the client would provide support but would not promote independence. It could lead to increased dependence on others for feeding and may reduce the client’s motivation to perform self-feeding.
Choice C reason: Asking the client if they would prefer a liquid diet is an important consideration for clients with swallowing difficulties, which can be a complication of a stroke. However, this does not directly promote independence in feeding if the client is capable of eating solid foods.
Choice D reason: Describing the location of the food on the tray helps the client understand where each item is placed, akin to a clock face orientation. This empowers the client to feed themselves independently, which is crucial for self-esteem and rehabilitation progress.
Similar Questions
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis.
Which of the following actions is the nurse's priority?
A. Document intake and output.
Document intake and output. Rationale: Documenting intake and output is an important aspect of nursing care, but it is not the top priority when a child has a suspected diagnosis of bacterial meningitis. Immediate interventions to address the underlying condition and prevent complications take precedence.
B. Administer antibiotics when available.
Administer antibiotics when available. Rationale: Administering antibiotics is the nurse's top priority when a child has a suspected diagnosis of bacterial meningitis. Timely antibiotic therapy is crucial to treat the infection and prevent its progression. Delaying antibiotic administration can lead to severe complications, including neurological damage and death.
C. Maintain seizure precautions.
Maintain seizure precautions. Rationale: Maintaining seizure precautions is important for clients with neurological conditions, including meningitis. However, it is not the nurse's top priority when bacterial meningitis is suspected. Immediate treatment with antibiotics takes precedence over seizure precautions.
D. Reduce environmental stimuli.
Reduce environmental stimuli. Rationale: Reducing environmental stimuli is a consideration in the care of clients with neurological conditions to prevent agitation and seizures. However, it is not the nurse's top priority when a child has a suspected diagnosis of bacterial meningitis. The primary focus should be on administering antibiotics promptly to address the infection.
A nurse is reinforcing teaching with a client who has diabetic neuropathy about foot care.
Which of the following instructions should the nurse include?
A. Wear open-toed shoes.
Wearing open-toed shoes is not recommended for clients with diabetic neuropathy because it increases the risk of foot injuries and infections. Closed-toed shoes provide better protection.
B. Wash feet in hot water.
Washing feet in hot water is not advisable as it can cause burns or damage to the skin, especially since clients with diabetic neuropathy may have reduced sensation and may not feel the temperature accurately. Lukewarm water should be used instead.
C. Avoid walking barefoot.
Avoiding walking barefoot is crucial for clients with diabetic neuropathy to prevent injuries, cuts, and infections. Walking barefoot increases the risk of stepping on sharp objects or developing sores that may go unnoticed due to reduced sensation.
D. Apply lotion between the toes.
Applying lotion between the toes is not recommended because it can create a moist environment that promotes fungal infections. Lotion should be applied to the tops and bottoms of the feet, but not between the toes.
Full Explanation
The correct answer is choice c. Avoid walking barefoot.
Choice A rationale:
Wearing open-toed shoes is not recommended for clients with diabetic neuropathy because it increases the risk of foot injuries and infections. Closed-toed shoes provide better protection.
Choice B rationale:
Washing feet in hot water is not advisable as it can cause burns or damage to the skin, especially since clients with diabetic neuropathy may have reduced sensation and may not feel the temperature accurately. Lukewarm water should be used instead.
Choice C rationale:
Avoiding walking barefoot is crucial for clients with diabetic neuropathy to prevent injuries, cuts, and infections. Walking barefoot increases the risk of stepping on sharp objects or developing sores that may go unnoticed due to reduced sensation.
Choice D rationale:
Applying lotion between the toes is not recommended because it can create a moist environment that promotes fungal infections. Lotion should be applied to the tops and bottoms of the feet, but not between the toes.
A nurse is collecting data regarding the pain level of a 3-year-old child on the second postoperative day following an appendectomy.
Which of the following actions should the nurse take?
A. Use the FACES Scale to assess the child's pain level.
Use the FACES Scale to assess the child's pain level. Rationale: The FACES Scale is a suitable pain assessment tool for a 3-year-old child. It uses facial expressions to assess pain intensity, making it a child-friendly and reliable option for assessing pain in young children who may have difficulty using numeric or visual analog scales.
B. Use a numeric scale to assess the child's pain level.
Use a numeric scale to assess the child's pain level. Rationale: Using a numeric pain scale may not be appropriate for a 3-year-old child, as they may have limited understanding of numbers and may struggle to express their pain using this method. The FACES Scale or other age-appropriate tools are more effective for this age group.
C. Use the Visual Analog Scale to assess the child's pain level.
Use the Visual Analog Scale to assess the child's pain level. Rationale: The Visual Analog Scale typically involves a line with endpoints representing "no pain" and "worst pain," and the child is asked to mark their pain level on the line. This scale may be challenging for a 3-year-old child to use effectively, as it requires a level of abstract thinking and
D. Use a color tool to assess the child's pain level.