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 C
Explanation
Choice A: CVA is a temporary neurologic deficit and a TIA is more long-term deficit is not correct, as it reverses the definitions of CVA and TIA.
Choice B: There is no difference is not correct, as there are significant differences between CVA and TIA in terms of duration, severity, and prognosis.
Choice C: TIA is a temporary neurologic deficit and a CVA is more long-term deficit is correct, as it accurately describes the difference between CVA and TIA. A TIA is a brief episode of neurologic dysfunction caused by focal brain ischemia that resolves within 24 hours, while a CVA is a permanent or lasting damage to brain tissue caused by ischemia or hemorrhage.
Choice D: CVA results from temporary impairment of blood flow and TIA is long-term impairment is not correct, as it reverses the causes of CVA and TIA.
Correct Answer is C
Explanation
Choice A: When patient no longer has numbness in extremities is incorrect because it is not a reliable indicator of cervical spine injury or recovery. Numbness in extremities can be caused by various factors such as nerve compression, inflammation, or medication. It can also persist or recur after the cervical collar is removed. The nurse should assess the patient's neurological status but should not remove the cervical collar based on this symptom alone.
Choice B: When patient states they have no pain in the neck is incorrect because it is also not a reliable indicator of cervical spine injury or recovery. Pain in the neck can be subjective, variable, or masked by other factors such as analgesics, shock, or distraction. It can also be absent or delayed after the cervical collar is removed. The nurse should assess the patient's pain level but should not remove the cervical collar based on this symptom alone.
Choice C: When doctor has cleared patient following a cervical X-ray is correct because it is the safest and most accurate way to determine if the patient has a cervical spine injury or not. A cervical X-ray can show any fractures, dislocations, or other abnormalities in the cervical vertebrae that may require immobilization or surgery. The nurse should follow the doctor's orders and remove the cervical collar only after the doctor has confirmed that there is no risk of further damage to the spinal cord or nerves.
Choice D: All of the above are incorrect because only choice c) is sufficient and necessary to remove the cervical collar from a head injury patient. Choices a) and b) are not valid criteria and may expose the patient to potential harm or complications. The nurse should use evidence-based practice and follow the protocols for head injury management and care.
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