The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch.
What action by the new nurse would cause the precepting nurse to intervene?
The patient is lying in bed with their head elevated to 35 degrees.
The nurse provides thickened liquids per the orders.
The nurse does not rush the patient in eating each bite.
The nurse ensures that the patient’s food is minced.
The Correct Answer is A
Choice A rationale
The patient lying in bed with their head elevated to 35 degrees while eating could pose a risk for aspiration, especially for a patient with Huntington’s disease. Huntington’s disease is a neurodegenerative disorder that can cause difficulties with swallowing and motor control.
Therefore, it is recommended that the patient be as upright as possible, ideally in a seated position, during meals to reduce the risk of aspiration.
Choice B rationale
Providing thickened liquids is a common intervention for patients with Huntington’s disease who have difficulty swallowing. Thickened liquids are easier to control and swallow, reducing the risk of aspiration.
Choice C rationale
Not rushing the patient in eating each bite is a recommended practice. Patients with Huntington’s disease often have difficulty with motor control, including swallowing. Allowing the patient to take their time can help prevent choking and aspiration.
Choice D rationale
Ensuring that the patient’s food is minced is another recommended practice for patients with Huntington’s disease. Minced food is easier to chew and swallow, which can help prevent choking and aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale
If a patient states that he cannot see the top of the Snellen chart, the nurse should determine whether the patient can count fingers. If the patient is unable to read the top line of the Snellen
chart at 6 meters, the nurse can reduce the distance to 3 meters from the Snellen chart. If the patient still cannot read the chart, the nurse can then determine whether the patient can count fingers.
Choice A rationale
While documenting findings is an important part of the nursing process, it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice C rationale
Obtaining a tumbling E chart to assess visual acuity could be considered if the patient is unable to read letters or numbers, but it would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Choice D rationale
Completing an internal eye exam would not be the immediate action the nurse should take if a patient cannot see the top of the Snellen chart.
Correct Answer is B
Explanation
Choice A rationale
While tremors and decreased mobility are common symptoms of Parkinson’s disease, they are not the most significant impact on a patient’s life. These physical symptoms can be managed with medication and physical therapy.
Choice B rationale
Loss of independence is often the most significant impact on a patient’s life. As the disease progresses, patients may find it increasingly difficult to perform daily activities and may require assistance.
Choice C rationale
Age-related changes can contribute to the progression of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The disease itself, rather than aging, is the primary cause of the symptoms.
Choice D rationale
Neurologic deficits are a result of Parkinson’s disease, but they are not the most significant impact on a patient’s life. The loss of independence that results from these deficits is often more impactful.
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