A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should:

Hold the feeding if the client has soft brown stools and is passing flatus.

Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL.

Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness.

Check for residual enteral formula prior to administration.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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Correct Answer is B

Explanation

Choice A rationale

The frontal lobe controls executive functions like reasoning and planning, not object identification errors. Damage here leads to issues with decision-making and voluntary movement, not misidentification of objects.

Choice B rationale

The temporal lobe processes auditory information and object recognition. Injury disrupts the brain's ability to associate visual stimuli with correct labels, causing errors like calling a pen "a key.”.

Choice C rationale

The parietal lobe processes sensory information related to touch, pain, and spatial awareness. Damage causes difficulty with spatial relations and perception but doesn't typically involve visual misidentification.

Choice D rationale

The occipital lobe handles visual processing. Damage affects vision or visual interpretation but does not impair the recognition or labeling of objects directly.

A. Is in the latent period of the disease. B. Continues to remain in HIV positive status. C. Has acquired immunodeficiency syndrome (AIDS). D. Has seroconverted.

Correct Answer is C

Explanation

Choice A rationale

The latent period of HIV includes asymptomatic phases when the CD4+ count remains above 200 cells/mm. Pneumocystic pneumonia and low CD4+ counts signify progression beyond latent HIV.

Choice B rationale

HIV-positive status reflects infection presence, but it does not confirm AIDS unless CD4+ count drops below 200 cells/mm and opportunistic infections occur, such as pneumocystic pneumonia.

Choice C rationale

AIDS is diagnosed when CD4+ count decreases below 200 cells/mm, coupled with opportunistic infections. Pneumocystic pneumonia indicates a weakened immune system due to advanced disease.

Choice D rationale

Seroconversion marks the initial immune response to HIV infection with detectable antibodies but occurs before CD4+ counts decline significantly and opportunistic infections appear.

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should:

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Correct Answer is B

Explanation

A client, who has tested positive for human immunodeficiency virus (HIV), now presents with a CD4+ count of less than 200 cells/mm and pneumocystic pneumonia.A normal range for a CD4+ count is 500-1500 cells/mm.How would the nurse evaluate these findings? The client:

Correct Answer is C

Explanation

A client with homonymous hemianopsia resulting from a stroke has a disturbed sensory perception.An appropriate nursing intervention to help the client learn to compensate for this deficit during the rehabilitation period would be to:

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A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.
For safe administration, the nurse should: