An older adult client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). The client has facial paralysis and cannot move the left side of the body. When entering the room, the nurse finds the client's spouse tearful and trying unsuccessfully to give the client a drink of water. Which action should the nurse take?
Obtain thickening powder before providing any more fluids.
Assist the spouse and carefully give the client small sips of water.
Ask the spouse to stop and assess the client's swallowing reflex.
Give the spouse a straw to help facilitate the client's drinking.
The Correct Answer is C
Rationale
A. Thickening powder is used to modify the consistency of liquids to prevent aspiration in clients with swallowing difficulties. This option suggests ensuring safety by thickening fluids to reduce the risk of choking or aspiration. However, this does not address the underlying issue.
B. This option involves immediate action to provide hydration under close supervision. It implies that the nurse will closely monitor the client's ability to swallow and assess for signs of aspiration during the process. However, it does not address the underlying risk.
C. This option focuses on assessing the client's ability to swallow before providing more fluids. It acknowledges the potential danger of giving fluids without knowing the client's current swallowing ability, which could lead to aspiration.
D. Providing a straw might seem helpful but could potentially increase the risk of aspiration if the client has swallowing difficulties. It does not address the immediate need for assessing the client's ability to swallow safely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Green leafy vegetables do not interact with cefdinir. They are generally a healthy choice and can be encouraged without any concerns related to the antibiotic therapy.
B. Fresh fruits are also safe to consume with cefdinir. There are no interactions between fruits and this antibiotic.
C. Yogurt and buttermilk contain probiotics, which are beneficial bacteria that can help maintain gut health. Antibiotics like cefdinir can disrupt the normal gut flora, leading to diarrhea or other gastrointestinal issues. Consuming yogurt or buttermilk with live cultures may help replenish beneficial bacteria in the gut and reduce the risk of antibiotic-associated diarrhea.
D. Avocados and cheese are also safe choices. There are no specific interactions between these foods and cefdinir.
Correct Answer is A
Explanation
Rationale
A. Pairing the newly hired UAP with the most experienced UAP can provide mentoring and guidance. This allows the experienced UAP to share knowledge, demonstrate best practices, and help the new UAP navigate unfamiliar situations or complex care needs. It promotes skill development and ensures that care is provided effectively and safely.
B. Assigning less complex clients to the newly hired UAP initially can help ease them into their role and build confidence. It allows them to focus on learning routines, policies, and procedures without the added stress of managing highly complex care situations. However, this approach should be temporary and paired with opportunities for training and skill development.
C. Direct observation of the newly hired UAP's care delivery is crucial to assess their competency in various tasks. It provides firsthand insight into their skills, adherence to protocols, and ability to handle
client needs independently. Based on observations, appropriate feedback and additional training can be provided as needed.
D. Reviewing the UAP's skills checklist and discussing their previous experience with the hiring manager or supervisor provides essential background information. This helps in understanding the UAP's strengths, areas for improvement, and any specific training needs. It ensures that appropriate assignments and support are provided based on their skill level.
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