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.

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Correct Answer is C

Explanation

Choice A rationale

While a headache with sudden onset can be a symptom of various conditions, it is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice B rationale

Flat jugular vein distention (JVD) at 45 degrees is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice C rationale

An abnormal level of consciousness can be a sign of decreased cerebral perfusion, which can occur in a client with atrial fibrillation and a rapid ventricular rate. This is a critical finding that should be reported to the healthcare provider immediately.

Choice D rationale

Nausea with vomiting is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

A. Resume normal physical activity. B. Administer a dose of regular insulin as prescribed. C. Consume electrolyte fluid replacements. D. Monitor urine output over the next 24 hours.

Correct Answer is B

Explanation

Choice A rationale

Resuming normal physical activity is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of Diabetic Ketoacidosis (DKA). Physical activity can increase blood glucose levels, which could exacerbate the condition.

Choice B rationale

Administering a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a patient with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.

Choice C rationale

Consuming electrolyte fluid replacements is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While hydration is important, it does not address the underlying issue of high blood sugar levels.

Choice D rationale

Monitoring urine output over the next 24 hours is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While it is important to monitor urine output in patients with diabetes, it does not address the underlying issue of high blood sugar levels.

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Naxlex Comprehensive Predictor Exams

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

When educating a patient newly diagnosed with type 1 diabetes mellitus, the nurse explains that increased thirst is an early sign of Diabetic Ketoacidosis (DKA). What action should the nurse advise the patient to take if this sign of DKA appears?

Correct Answer is B

Explanation

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