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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

Choice A rationale

The statement “This diagnosis means that I am crazy” requires follow-up teaching by the nurse. Mental health conditions do not equate to being “crazy”. It’s important to educate the client about the nature of their diagnosis and dispel any misconceptions.

Choice B rationale

The statement “Many people have the same response to a stressful situation as I am having right now” does not require follow-up teaching. It shows that the client understands that their reaction to stress is not uncommon.

Choice C rationale

The statement “I will probably need to be on medication for the rest of my life” requires follow-up teaching. While some conditions do require long-term medication, it’s not a certainty for all conditions. The duration of treatment can vary based on the individual’s response and the nature of their condition.

Choice D rationale

The statement “I can use holistic approaches like meditation to help my symptoms” does not require follow-up teaching. It shows that the client is open to using non-pharmacological methods to manage their symptoms, which can be a beneficial part of a comprehensive treatment plan.

Choice E rationale

The statement “I am at high risk for post-traumatic stress disorder because I have acute stress disorder” does not require follow-up teaching. It’s accurate that individuals with acute stress disorder are at a higher risk of developing post-traumatic stress disorder.

Choice F rationale

The statement “I can learn to manage my thoughts better through therapy” does not require follow-up teaching. It shows that the client understands the benefits of therapy in managing their condition.

A. Auscultate an area six inches below the umbilicus. B. Observe the appearance of the patient’s urine. C. Palpate the area above the pubic symphysis. D. Measure the girth of the patient’s lower abdomen.

Correct Answer is C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client statements require follow-up teaching by the nurse? Select all that apply.

Correct Answer is ["A","C"]

Explanation

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

The nurse has reviewed the patient’s chart.The nurse recognizes that this patient is hemorrhaging due to which condition?

A newly recruited unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs.What intervention should the home health nurse implement to ensure adequate care for all clients?

Exhibits The nurse notifies the healthcare provider of the client’s status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply. Potential Actions

What breakfast option should a nurse suggest for a 16-year-old patient suffering from diarrhea?

Following the administration of albuterol and the subsequent assessment, what actions should the nurse plan for the rest of the shift?

A healthcare provider prescribes a low-fiber diet for a patient with ulcerative colitis.Which food selection by the patient indicates to the nurse that the patient understands the prescribed diet?