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Difficulty: MediumBasic Care and Comfort

A nurse is caring for a 75-year-old client with severe bilateral macular degeneration who is struggling to navigate their meal tray due to visual impairment. The client is alert and oriented with no history of swallowing difficulties. Which of the following nursing actions is most appropriate to promote the client's independence and adequate nutritional intake?

  1. Describe the location of the food items on the plate using the numbers on a clock face.Answer
  2. B
    Position the client in a low-Fowler's position at 15 degrees to ensure comfort while eating.
  3. C
    Delegate the initial observation of the client's swallowing coordination to the unlicensed assistive personnel (UAP).
  4. D
    Request a prescription for a pureed diet, as difficulty eating is a normal physiological expectation at this age.

Answer

Describe the location of the food items on the plate using the numbers on a clock face.
For a client with severe visual impairment who is otherwise alert and able to swallow, the goal is to provide environmental accommodations that promote self-care. Describing the food arrangement using the numbers on a clock face (e.g., 'chicken is at 6 o'clock, peas are at 2 o'clock') provides clear spatial orientation, allowing the client to feed themselves safely and maintain their dignity.

Step-by-Step Solution

1
Assess the client's barriers to adequate nutritional intake.
The primary barrier is identified as visual impairment due to macular degeneration, not cognitive decline or dysphagia.
Accurate identification of the barrier determines the appropriate nursing intervention.
2
Select an intervention that addresses the visual deficit while maintaining client autonomy.
The clock face method is chosen as the optimal communication tool.
This method provides a universal spatial reference that allows the client to locate food independently without taking away their ability to feed themselves.
3
Ensure safe positioning and appropriate delegation during the meal.
The client is placed in a high-Fowler's position, and the RN conducts any necessary swallowing assessments.
Proper positioning prevents aspiration, and RNs must perform all initial clinical assessments.

Key Concept

Basic Care and Comfort: Nutrition and Visual Impairment
Estimated Time:1m 0s
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Topics

Basic Care and Comfort

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