A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Positions the head with the chin tilted slightly downward.

Raises the head of the bed to 60 degrees.

Places food on the unaffected side of the mouth.

Allows 30 minutes of rest before feeding.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is correct because 60 degrees is not fully upright and may not provide optimal protection against aspiration. The client should ideally be positioned at 90 degrees during meals if tolerated indicating need for additional teaching

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is incorrect because resting before meals decreases fatigue and improves swallowing ability.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because fluid volume deficit is a life-threatening condition that can result from diarrhea and fecal incontinence. The nurse should monitor the client's fluid intake and output, electrolytes, weight, urine specific gravity, and skin turgor.

Choice B Reason: This is incorrect because bowel incontinence is a significant problem that can affect the client's dignity, comfort, and skin integrity, but it is not as urgent as fluid volume deficit. The nurse should implement a bowel management program and provide appropriate hygiene and skin care.

Choice C Reason: This is incorrect because caregiver role strain is a potential problem that can affect the parent's well-being and ability to provide care, but it is not as critical as fluid volume deficit. The nurse should assess the parent's coping skills, support system, and respite needs.

Choice D Reason: This is incorrect because impaired bed mobility is a chronic problem that can affect the client's functional status and quality of life, but it is not as serious as fluid volume deficit. The nurse should assist the client with positioning, turning, transferring, and exercising.

A. "I'm sorry, but your child's medical information is none of your business." B. "I can give you those results as soon as I get them back from the lab." C. "The healthcare provider will share this information with you." D. "I can only give medical information to your child because they are legally an adult."

Correct Answer is D

Explanation

Choice A: "I'm sorry, but your child's medical information is none of your business." is not a good response because it is rude and disrespectful. The nurse should maintain professionalism and empathy when dealing with parents.

Choice B: "I can give you those results as soon as I get them back from the lab." is not a good response because it violates confidentiality and privacy. The nurse should not share any medical information with anyone without the client's consent.

Choice C: "The healthcare provider will share this information with you." is not a good response because it implies that the parents have a right to know their child's medical information. The nurse should not make promises or assumptions that may not be true.

Choice D: "I can only give medical information to your child because they are legally an adult." is a good response because it explains the legal status of an emancipated minor and respects their autonomy. The nurse should inform the parents that their child has the right to make their own decisions regarding their health care.

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A client who had a cerebral vascular accident (CVA) and is at risk for aspiration is being fed by an unlicensed assistive personnel (UAP). Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies several nursing problems for a client with paraplegia who has been having fecal incontinence and diarrhea. The client's parent is the primary caregiver. In planning care, the nurse should determine which problem is the highest priority?

Correct Answer is A

Explanation

A 16-year-old emancipated client is being seen in the emergency department following a minor automobile accident. The client's parents arrive and are asking questions about the client's laboratory results. Which response is best for the nurse to provide?

Correct Answer is D

Explanation

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