The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Assist the client to lie down and turn to the side.

Recommend the use of supplemental liquid feedings.

Demonstrate use of a tucked-chin position while eating.

Encourage the use of assistive feeding devices.

Answer and Explanation

The Correct Answer is C

Choice A reason: Assisting the client to lie down may increase the risk of aspiration.

Choice B reason: Supplemental liquid feedings may be considered but do not address the immediate issue.

Choice C reason: Demonstrating the tucked-chin position can help reduce the risk of aspiration by ensuring the airway is protected during swallowing.

Choice D reason: Assistive feeding devices may help but do not address the immediate issue of frequent coughing during meals.

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Free Nursing Study Resources

Correct Answer is ["A","C","E"]

Explanation

Choice A reason: Measuring the client's vital signs before walking helps ensure the client's stability and readiness for activity.

Choice B reason: Determining the need for a gait belt is typically the responsibility of the nurse, not the UAP.

Choice C reason: Reporting dizziness or lightheadedness is important for monitoring the client's response to activity and preventing falls.

Choice D reason: Instructing the client about orthostatic hypotension is not within the scope of practice for a UAP.

Choice E reason: Assisting the client to void before walking can prevent discomfort and the need for an urgent restroom break during the activity.

A. Have the adolescent list the procedural steps for safe insulin administration. B. Review his glycosylated hemoglobin level 3 months after the teaching session. C. Observe him as he demonstrates the self-injection technique to another diabetic adolescent. D. Ask the adolescent to describe his level of comfort with injecting himself with insulin.

Correct Answer is C

Explanation

Choice A reason: Listing the procedural steps is helpful but does not demonstrate practical competence.

Choice B reason: Reviewing glycosylated hemoglobin levels provides information about long-term glucose control but does not directly assess the technique.

Choice C reason: Observing the adolescent as he demonstrates the self-injection technique ensures that he has understood and can correctly perform the procedure, providing the best evaluation of teaching effectiveness.

Choice D reason: Describing the level of comfort provides insight into his confidence but not necessarily his technical competence.

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The home health nurse makes a home visit to a client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding themselves and coughs frequently during the meal. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

The nurse is teaching a male adolescent recently diagnosed with type 1 diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate the effectiveness of the teaching?

Correct Answer is C

Explanation

The nurse observes an unlicensed assistive personal (UAP) washing hands prior to entering the client's room. Which action by the UAP requires additional teaching?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

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Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

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