Maintaining skin integrity would include:
Nutrition supplements
Consulting speech therapy
Assessing the skin and frequent repositioning
Ambulating the patient as much as possible
The Correct Answer is C
Choice A: Nutrition supplements is not a direct intervention for maintaining skin integrity, but rather a general measure to support the patient's overall health and healing.
Choice B: Consulting speech therapy is not relevant for maintaining skin integrity, but rather for addressing the patient's communication and swallowing needs.
Choice C: Assessing the skin and frequent repositioning is a correct intervention for maintaining skin integrity, as it can prevent pressure ulcers or bedsores by reducing friction, shear, and moisture on the skin.
Choice D: Ambulating the patient as much as possible is not a specific intervention for maintaining skin integrity, but rather a general measure to promote the patient's mobility and circulation.
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: 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.
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