A nurse and an assistive personnel (AP) are providing care for four clients who were admitted to the medical-surgical unit on the previous shift. The nurse should delegate meal assistance for which of the following clients to the AP?
A client who has Guillain-Barré syndrome
A client who has systemic sclerosis
A client who has amyotrophic lateral sclerosis (ALS)
A client who has a lumbosacral spinal tumor
The Correct Answer is D
Choice A reason:
A client who has Guillain-Barré syndrome: Guillain-Barré syndrome (GBS) can cause significant muscle weakness and paralysis, including the muscles involved in swallowing. Clients with GBS are at high risk for aspiration and may require specialized feeding techniques or assistance from a nurse rather than an AP.
Choice B reason:
A client who has systemic sclerosis: Systemic sclerosis, also known as scleroderma, can affect the esophagus and cause difficulty swallowing. These clients may need careful monitoring and assistance with meals to prevent choking and ensure adequate nutrition.
Choice C reason:
A client who has amyotrophic lateral sclerosis (ALS): ALS affects the motor neurons and can lead to progressive muscle weakness, including the muscles involved in swallowing. Clients with ALS often require specialized feeding techniques and close monitoring during meals to prevent aspiration.
Choice D reason:
A client who has a lumbosacral spinal tumor: A lumbosacral spinal tumor primarily affects the lower back and may cause pain or mobility issues, but it does not typically impair swallowing. Therefore, this client is the most appropriate for the AP to assist with meals, as they are less likely to have complications related to eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: You Can Expect Swelling of the Ankles While Taking This Medication
Swelling of the ankles, or peripheral edema, is a known side effect of verapamil. This calcium channel blocker can cause fluid retention, leading to swelling in the lower extremities. While this is a common side effect, it is not an instruction that the nurse should include in discharge teaching. Instead, the nurse should inform the client to report any significant swelling to their healthcare provider.
Choice B reason: Do Not Take This Medication on an Empty Stomach
Verapamil can be taken with or without food, but taking it with food may help reduce stomach upset. Therefore, the instruction to avoid taking it on an empty stomach is not strictly necessary. The nurse should advise the client to follow their healthcare provider’s specific instructions regarding medication administration.
Choice C reason: Limit Your Fluid Intake to Meal Times
Limiting fluid intake to meal times is not a standard recommendation for clients taking verapamil. Adequate hydration is important for overall health, and there is no specific reason to restrict fluid intake while on this medication. The nurse should encourage the client to maintain a balanced fluid intake throughout the day.
Choice D reason: Increase Your Daily Intake of Dietary Fiber
Increasing daily intake of dietary fiber is a beneficial instruction for clients taking verapamil. Verapamil can cause constipation as a side effect, and a high-fiber diet can help mitigate this issue. Foods rich in fiber, such as fruits, vegetables, and whole grains, can promote regular bowel movements and improve digestive health.
Correct Answer is B
Explanation
Choice A reason:
While articulating expectations is important, the nurse’s response is more focused on addressing the client’s feelings and encouraging participation in therapy. Simply stating expectations without addressing the client’s emotions may not be as effective.
Choice B reason:
The nurse’s response demonstrates empathy by acknowledging the client’s feelings and gently guiding them towards participating in group therapy. This approach helps build trust and rapport, which are essential in therapeutic relationships, especially with clients exhibiting delusional behavior.
Choice C reason:
Setting limits on manipulative behavior is important, but in this context, the nurse’s response is more about encouraging participation and showing understanding rather than strictly setting limits.
Choice D reason:
Reflection involves mirroring the client’s feelings or statements to show understanding. While the nurse’s response does show understanding, it is not a direct example of reflection. The primary focus is on empathy and encouragement.
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