A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
A client who has Guillain-Barré syndrome
A client who has systemic sclerosis
A client who has amyotrophic lateral sclerosis (ALS)
A client who has a lumbosacral spinal tumor
The Correct Answer is D
Choice A reason:
A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.
Choice B reason:
A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.
Choice C reason:
A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.
Choice D reason:
A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Smallpox
Smallpox is a viral disease caused by the variola virus. It was eradicated globally in 1980 through a successful vaccination campaign. Treatment for smallpox primarily involves supportive care and antiviral medications, such as tecovirimat, rather than antibiotics like ciprofloxacin. Ciprofloxacin is ineffective against viral infections, including smallpox.
Choice B reason: Anthrax
Anthrax is a serious infectious disease caused by the bacterium Bacillus anthracis. Ciprofloxacin is one of the primary antibiotics used for the treatment and post-exposure prophylaxis of anthrax. It works by inhibiting bacterial DNA gyrase, which is essential for bacterial replication. Ciprofloxacin is effective against both cutaneous and inhalational forms of anthrax, making it a critical component in the management of anthrax exposure.
Choice C reason: Ebola virus
Ebola virus disease (EVD) is caused by the Ebola virus, a member of the Filoviridae family. Treatment for EVD primarily involves supportive care, including rehydration and management of symptoms. Antiviral medications, such as remdesivir, may also be used. Ciprofloxacin, being an antibiotic, is not effective against viral infections like Ebola.
Choice D reason: Sarin gas
Sarin gas is a highly toxic nerve agent used in chemical warfare. Exposure to sarin gas requires immediate medical intervention, including the administration of antidotes such as atropine and pralidoxime, as well as supportive care. Antibiotics like ciprofloxacin are not used in the treatment of chemical agent exposure, as they do not counteract the effects of nerve agents.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A: WBC Count
Reason: The white blood cell (WBC) count is not directly related to fall risk. WBC count is an indicator of the immune system’s response to infection or inflammation. In this case, the patient’s WBC count is within the normal range (5,000 to 10,000/mm³) on both days. Therefore, it does not contribute to an increased risk of falls.
Choice B: Parkinson’s disease
Reason: Parkinson’s disease significantly increases the risk of falls due to several factors. Patients with Parkinson’s often experience postural instability, which is the inability to maintain balance when standing or walking. This condition is a cardinal feature of Parkinson’s disease and can lead to frequent falls. Additionally, Parkinson’s patients may experience freezing of gait, where they suddenly cannot move their feet forward despite the intention to walk. This can cause them to fall. Other gait abnormalities, such as festinating gait (short, rapid steps) and dyskinesias (involuntary movements), also contribute to the increased fall risk.
Choice C: Potassium level on day 2
Reason: The patient’s potassium level on day 2 is 3.0 mEq/L, which is below the normal range of 3.5 to 5 mEq/L. Low potassium levels (hypokalemia) can lead to muscle weakness, cramps, and fatigue. These symptoms can impair the patient’s ability to maintain balance and increase the risk of falls. Hypokalemia can also cause abnormal heart rhythms, which can further contribute to the risk of falls.
Choice D: Furosemide
Reason: Furosemide is a diuretic medication used to treat conditions such as heart failure by reducing fluid buildup in the body. However, it can also cause orthostatic hypotension, a condition where blood pressure drops significantly when standing up. This can lead to dizziness, lightheadedness, and an increased risk of falls. Additionally, furosemide can cause electrolyte imbalances, such as low potassium levels, which can further contribute to fall risk.
Choice E: Low blood pressure
Reason: The patient’s blood pressure readings indicate orthostatic hypotension, with a significant drop from 128/56 mm Hg while sitting to 92/40 mm Hg while standing. Orthostatic hypotension is a common condition in patients with Parkinson’s disease and heart failure. It can cause dizziness, lightheadedness, and fainting when changing positions, increasing the risk of falls. The patient’s low blood pressure when standing is a clear indicator of increased fall risk.
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