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 B
Explanation
Choice A reason:
Wiping from back to front is incorrect and can lead to contamination of the urine sample with bacteria from the anal area. The correct method is to wipe from front to back to reduce the risk of contamination.
Choice B reason:
Urinating a small amount in the toilet before collecting the sample is the correct procedure for obtaining a midstream urine specimen. This helps to flush out any bacteria or contaminants from the urethra, ensuring that the sample collected is as clean as possible.
Choice C reason:
Letting the urine cool to room temperature before sending it to the lab is incorrect. Urine samples should be sent to the lab as soon as possible after collection to ensure accurate results. If there is a delay, the sample should be refrigerated.
Choice D reason:
It is generally recommended to avoid collecting a urine sample during menstruation, as menstrual blood can contaminate the sample and affect the test results.
Correct Answer is C
Explanation
Choice A reason:
Distorted perceptual field is more commonly associated with severe anxiety or panic attacks rather than moderate anxiety. In severe anxiety, a person’s ability to perceive reality can be significantly impaired, leading to distorted perceptions and an inability to focus.
Choice B reason:
Urinary frequency can be a symptom of anxiety, but it is not specifically indicative of moderate anxiety. It can occur in various levels of anxiety, including mild, moderate, and severe. However, it is not as prominent a symptom as others like rapid speech or restlessness.
Choice C reason:
Rapid speech is a common symptom of moderate anxiety. Individuals with moderate anxiety often exhibit signs of increased nervousness and agitation, which can manifest as rapid or pressured speech. This symptom reflects the heightened state of arousal and the difficulty in controlling anxious thoughts.
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