Assisting a stroke patient with feeding would include:
Head of bed 45 degrees
Patient should be on a regular diet to rebuild their swallowing ability
Have patient sit upright 90 degrees in bed or chair
All of the above
The Correct Answer is C
Choice A: Head of bed 45 degrees is not enough to prevent aspiration or choking, as the patient may still have difficulty swallowing and clearing their airway.
Choice B: Patient should be on a regular diet to rebuild their swallowing ability is not correct, as the patient may need a modified diet depending on their level of dysphagia or swallowing impairment. A regular diet may pose a risk of aspiration or choking.
Choice C: Have patient sit upright 90 degrees in bed or chair is correct, as this position helps the patient align their head and neck and use gravity to facilitate swallowing and prevent aspiration.
Choice D: All of the above is not correct, as only choice C is appropriate for assisting a stroke patient with feeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Respiratory status is the first priority, as it can affect the oxygenation and perfusion of the brain and other vital organs. The nurse should assess the rate, rhythm, depth, and quality of breathing, as well as the use of accessory muscles, chest expansion, and lung sounds.
Choice B: Alertness is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to open their eyes spontaneously or in response to stimuli, as well as their orientation to person, place, time, and situation.
Choice C: Motor response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to move their limbs voluntarily or in response to stimuli, as well as their muscle strength, tone, and coordination.
Choice D: Verbal response is not the first priority, but rather a component of the level of consciousness. The nurse should assess the patient's ability to speak clearly and coherently, as well as their content and appropriateness of speech.
Correct Answer is D
Explanation
Choice A: Incontinence is a cause of skin breakdown, as it can expose the skin to moisture, bacteria, and chemicals that can irritate and damage the skin.
Choice B: Altered level of consciousness is a cause of skin breakdown, as it can impair the patient's ability to sense and report pain, discomfort, or pressure on the skin.
Choice C: Immobility is a cause of skin breakdown, as it can reduce the blood flow and oxygen to the skin and increase the pressure on bony prominences.
Choice D: All of the above is correct, as all of these factors can contribute to skin breakdown.
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