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. 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.
Correct Answer is B
Explanation
Rationale
A. Starting IV infusion for antiviral drugs is premature without confirmation of COVID-19 diagnosis. Antiviral treatment for COVID-19 is typically initiated based on positive test results and clinical assessment by the healthcare provider. It is important to wait for test results before starting specific treatment protocols.
B. Given the client's symptoms and exposure history to someone with COVID-19, it is crucial to implement droplet precautions. This includes placing the client in a private room with the door closed to minimize the risk of airborne transmission. Healthcare providers should wear appropriate personal protective equipment (PPE), including masks (N95 respirator or surgical mask), gown, gloves, and eye protection, when entering the room.
C. This action is appropriate to inform family members about potential exposure to COVID-19. Symptoms can develop up to 14 days after exposure, so monitoring for symptoms is essential. However, immediate isolation and precautions for the client are more critical at this stage.
D. While it is important for the client to inform others about potential exposure, the immediate concern is implementing isolation precautions for the client and preventing further transmission within the healthcare setting.
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.