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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Supported Sims: The Supported Sims position involves lying on one side with the lower arm behind the back and the upper thigh flexed. This position is not typically recommended for postoperative cholecystectomy patients as it does not provide optimal support for breathing and comfort.
Choice B reason:
Semi-Fowler’s: The Semi-Fowler’s position, where the head of the bed is elevated to about 30-45 degrees, is ideal for postoperative cholecystectomy patients. This position helps facilitate breathing, reduces the risk of aspiration, and promotes comfort by reducing tension on the abdominal muscles.
Choice C reason:
Dorsal recumbent: The Dorsal recumbent position involves lying flat on the back with knees bent and feet flat on the bed. While this position can be used for certain procedures, it is not the most comfortable or beneficial for postoperative cholecystectomy patients as it can increase abdominal pressure and discomfort.
Choice D reason:
Prone: The Prone position, where the patient lies flat on their stomach, is not suitable for postoperative cholecystectomy patients. This position can cause discomfort and does not support optimal breathing or reduce abdominal tension.
Correct Answer is D
Explanation
Choice A reason: Painful urination
Painful urination, or dysuria, is not a typical symptom of benign prostatic hyperplasia (BPH). BPH primarily affects the flow of urine due to the enlargement of the prostate gland, which can obstruct the urethra. While BPH can cause discomfort, it does not usually result in painful urination. Painful urination is more commonly associated with urinary tract infections (UTIs) or other conditions affecting the urinary tract.
Choice B reason: Urge incontinence
Urge incontinence, characterized by a sudden and intense urge to urinate followed by involuntary loss of urine, can occur in some cases of BPH but is not the most common symptom. BPH typically causes symptoms related to urinary obstruction, such as difficulty starting urination, weak urine stream, and incomplete bladder emptying. Urge incontinence may develop if the bladder becomes overactive due to the obstruction, but it is not a primary symptom.
Choice C reason: Critically elevated prostate-specific antigen (PSA) level
While an elevated prostate-specific antigen (PSA) level can be associated with BPH, it is not a definitive finding. PSA levels can be elevated due to various conditions, including prostate cancer, prostatitis, and BPH. However, a critically elevated PSA level is more concerning for prostate cancer rather than BPH. Therefore, while PSA testing is useful in the evaluation of prostate conditions, it is not specific to BPH.
Choice D reason: Difficulty starting the flow of urine
Difficulty starting the flow of urine, also known as hesitancy, is a hallmark symptom of BPH. The enlarged prostate gland can compress the urethra, making it difficult for urine to pass through. This can lead to a weak urine stream, straining to urinate, and a feeling of incomplete bladder emptying. These symptoms are collectively known as lower urinary tract symptoms (LUTS) and are commonly associated with BPH.
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