A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Walk to the other side of the bed and try again.

Wave a hand in front of the patient's face.

Speak more loudly and clearly.

Use a picture board to explain to the patient what the nurse is going to do.

Answer and Explanation

The Correct Answer is A

A. Walk to the other side of the bed and try again: The patient may have right-sided neglect due to the stroke, meaning they are not aware of stimuli on the left side. Approaching from the other side where the patient has better perception might help them respond better.
B. Wave a hand in front of the patient's face: This might not be effective and can startle the patient. It does not address the underlying issue of spatial neglect.
C. Speak more loudly and clearly: There is no indication that the patient has hearing loss or language comprehension issues. Speaking louder may not be effective if the patient is experiencing spatial neglect.
D. Use a picture board to explain to the patient what the nurse is going to do: This is a good strategy for communication but does not address the immediate need to reposition to a more effective approach to gain the patient’s attention first.

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Correct Answer is A

Explanation

A. "Smoking cessation is important because nicotine is a vasoconstrictor.": Buerger disease is strongly associated with tobacco use, and nicotine causes vasoconstriction, which exacerbates the condition. Smoking cessation is crucial in managing and preventing progression.
B. "Adequate fluid intake is important to maintain blood pressure.": While staying hydrated is generally important, it is not specifically related to the management of Buerger disease, which is more focused on vascular health and smoking cessation.
C. "Those most affected are middle-aged women after menopause.": Buerger disease predominantly affects young male smokers, not middle-aged women.
D. "A low-fat diet is required to reduce atherosclerosis in large arteries.": Buerger disease involves inflammation and thrombosis in small and medium-sized arteries and veins, not atherosclerosis in large arteries. Therefore, a low-fat diet, while beneficial for general cardiovascular health, is not specifically targeted for Buerger disease.

A. Have the patient swallow twice after each bite. B. Place the patient in a semi-Fowler position. C. Provide clear liquids only until the patient can swallow solid foods. D. Check the patient's mouth for pocketing of food. E. Encourage the use of a straw for liquids. F. Place food on the unaffected side of the patient's mouth.

Correct Answer is ["A","D","F"]

Explanation

A. Have the patient swallow twice after each bite: This can help clear any residual food from the mouth and reduce the risk of aspiration.
B. Place the patient in a semi-Fowler position: This position is not ideal for preventing aspiration. The patient should be in an upright, high Fowler’s position to minimize the risk.
C. Provide clear liquids only until the patient can swallow solid foods: Clear liquids can actually be more difficult to control in the mouth and throat than thicker liquids and may increase the risk of aspiration.
D. Check the patient's mouth for pocketing of food: Ensuring that no food is left in the mouth can help prevent aspiration after the patient has finished eating.
E. Encourage the use of a straw for liquids: Using a straw can increase the risk of aspiration because it delivers liquids quickly and may overwhelm the swallowing mechanism, especially in patients with dysphagia.
F. Place food on the unaffected side of the patient's mouth: This helps ensure that the stronger side of the mouth and throat manages the food, reducing the risk of aspiration.

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A patient is hospitalized poststroke. The nurse approaches the patient from the patient's left side to provide morning care. The patient is staring straight ahead and does not respond to the nurse's presence or voice. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing teaching to a patient with Buerger disease. Which of the following statements by the patient would the nurse evaluate as indicating understanding about Buerger disease?

Correct Answer is A

Explanation

A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. Which nursing interventions might be recommended to help prevent aspiration during eating? Select all that apply. (Select All that Apply.)

Correct Answer is ["A","D","F"]

Explanation

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