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 A
Explanation
Choice A reason:
The first step in removing an NG tube is to verify the provider’s prescription to discontinue the tube. This ensures that the removal is authorized and appropriate for the client’s current condition.
Choice B reason:
Disconnecting the tube from the wall suction is an important step, but it should be done after verifying the provider’s prescription. This step prevents any suction-related complications during the removal process.
Choice C reason:
Performing hand hygiene is crucial to prevent infection, but it is not the first step. Hand hygiene should be performed after verifying the provider’s prescription and before touching the client or any equipment.
Choice D reason:
Providing mouth care to the client is important for comfort and hygiene, but it is not the first step in the process of removing an NG tube. This can be done after the tube has been safely removed.
Correct Answer is C
Explanation
Choice A reason:
Reduced chest width: Aging does not typically result in a reduced chest width. Instead, changes in posture and the curvature of the spine can make the chest appear less prominent. The primary musculoskeletal changes with aging involve bone density, muscle mass, and joint flexibility
Choice B reason:
Increased force of isometric contraction: This is incorrect. Aging is associated with a decrease in muscle strength and mass, not an increase. The force of muscle contractions generally diminishes with age due to the loss of muscle fibers and changes in muscle composition.
Choice C reason:
Decreased muscle mass: This is correct. One of the most significant age-related musculoskeletal changes is sarcopenia, which is the loss of muscle mass and strength. This process begins around the age of 30 and accelerates with age, leading to decreased physical strength and increased risk of falls and fractures.
Choice D reason:
Thickened vertebral discs: Aging typically leads to the thinning and dehydration of intervertebral discs, not thickening. This can result in a reduction in height and increased susceptibility to spinal issues such as herniated discs and spinal stenosis.
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