An elderly patient has been admitted with a suspected stroke.
The patient has facial paralysis and is unable to move the left side of their body.
Upon entering the room, the nurse observes the patient’s spouse attempting to give the patient a drink of water, but struggling.
What should the nurse’s next course of action be?
Assist the spouse and carefully give the patient small sips of water.
Obtain thickening powder before providing any more fluids.
Ask the spouse to stop and assess the patient’s swallowing reflex.
Give the spouse a straw to help facilitate the patient’s drinking.
The Correct Answer is C
Choice A rationale
Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.
Choice B rationale
While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.
Choice C rationale
The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.
Choice D rationale
Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Walking at least once an hour at work can be beneficial for overall health and can contribute to maintaining energy balance. However, it may not be the most effective action for maintaining energy balance for a person who already exercises 2 to 3 times per week.
Choice B rationale
Increasing exercise intensity can help burn more calories and can contribute to maintaining energy balance. However, it’s important to note that exercise alone may not be sufficient for maintaining energy balance if not combined with a balanced diet.
Choice C rationale
Avoiding foods with high carbohydrate levels is not necessarily an effective action for maintaining energy balance. Carbohydrates are a primary source of energy for the body. While it’s important to choose complex carbohydrates over simple ones, avoiding carbohydrates altogether is not recommended.
Choice D rationale
Selecting foods that are lower in caloric density is an effective action for maintaining energy balance. Foods that are lower in caloric density, such as fruits and vegetables, can provide essential nutrients without contributing excessive calories. This can help maintain energy balance and prevent weight gain.
Correct Answer is C
Explanation
Choice C rationale
In a hurricane disaster medical area, drinking water contaminated by sewage is a common source of contamination that could lead to diarrhea. Hurricanes and severe storms often result in flooding, which can contaminate drinking water supplies with sewage and other pollutants. This can lead to the spread of waterborne diseases, including those that cause diarrhea. Type 2 diabetes Explore
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.