The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?
Places food on the unaffected side of the mouth.
Raises the head of the bed to 80 degrees.
Positions the head with the chin tilted slightly downward.
Allows 30 minutes of rest before feeding.
The Correct Answer is B
A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.
B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.
C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.
D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Neutrophils are a type of white blood cell that play a key role in fighting infections.
An elevated neutrophil count can indicate the presence of an infection.
Therefore, before reporting the finding of a red, tender, and swollen wound at the site of the lesion to the healthcare provider, the nurse should note the client’s neutrophil count.
Choice A is not correct because hematocrit is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.
Choice B is not correct because serum is not a laboratory value.
Choice C is not correct because blood PT level is not the laboratory value that the nurse should note before reporting the finding to the healthcare provider.a
Correct Answer is B
Explanation
The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain.
Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system1.
Therefore, the nurse should document the finding as neuropathic pain.
Choice A is not correct because acute pain is a general term that does not specify the type of pain experienced by the patient.
Choice C is not correct because visceral pain refers to pain that originates from internal organs.
Choice D is not correct because nociceptive pain refers to pain caused by tissue damage or injury.
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