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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["0.5"]

Explanation

Step 1: Determine the dosage required. Required dosage = 1 mg

Step 2: Determine the concentration of the available solution. Available concentration = 1 mg/0.5 mL

Step 3: Calculate the volume to be administered. Volume to be administered = Required dosage ÷ Available concentration Volume to be administered = 1 mg ÷ (1 mg ÷ 0.5 mL)

Step 4: Perform the division. 1 ÷ (1 ÷ 0.5) = 1 ÷ 2 = 0.5

Step 5: Round the answer to the nearest tenth. Rounded volume = 0.5 mL

The nurse should administer 0.5 mL.

A. Place a pillow under the client’s head. B. Insert a padded tongue blade into the client’s mouth. C. Apply a face mask for oxygen administration. D. Gently restrain the client’s extremities.

Correct Answer is A

Explanation

Choice A reason:

Place a pillow under the client’s head: During a tonic-clonic seizure, it is crucial to protect the client’s head from injury. Placing a pillow or any soft object under the head can help prevent head trauma caused by the convulsions. Ensuring the client’s safety by protecting their head is a primary concern during a seizure.

Choice B reason:

Insert a padded tongue blade into the client’s mouth: This action is incorrect and potentially dangerous. Inserting any object into the mouth during a seizure can cause injury to the teeth, gums, or jaw. It can also obstruct the airway. The myth that a person can swallow their tongue during a seizure is false, and no object should be placed in the mouth.

Choice C reason:

Apply a face mask for oxygen administration: While providing oxygen can be beneficial after the seizure has ended, during the seizure, the priority is to ensure the client’s safety and prevent injury. Applying a face mask during the active phase of a seizure is not practical and can interfere with managing the seizure safely.

Choice D reason:

Gently restrain the client’s extremities: Restraining the client’s extremities during a seizure is not recommended. Attempting to restrain the movements can cause injury to both the client and the nurse. The focus should be on protecting the client from harm without restricting their movements.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 1 mg vitamin K to a newborn. The medication is available in 1 mg/0.5 mL. How much should the nurse administer? (Round to the nearest tenth. Use a leading zero when applicable. Do not use a trailing zero.)

Correct Answer is ["0.5"]

Explanation

A nurse enters a client’s room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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