The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch.
What action by the new nurse would cause the precepting nurse to intervene?

The patient is lying in bed with their head elevated to 35 degrees.

The nurse provides thickened liquids per the orders.

The nurse does not rush the patient in eating each bite.

The nurse ensures that the patient’s food is minced.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The patient lying in bed with their head elevated to 35 degrees while eating could pose a risk for aspiration, especially for a patient with Huntington’s disease. Huntington’s disease is a neurodegenerative disorder that can cause difficulties with swallowing and motor control.
Therefore, it is recommended that the patient be as upright as possible, ideally in a seated position, during meals to reduce the risk of aspiration.
Choice B rationale

Providing thickened liquids is a common intervention for patients with Huntington’s disease who have difficulty swallowing. Thickened liquids are easier to control and swallow, reducing the risk of aspiration.
Choice C rationale
Not rushing the patient in eating each bite is a recommended practice. Patients with Huntington’s disease often have difficulty with motor control, including swallowing. Allowing the patient to take their time can help prevent choking and aspiration.
Choice D rationale
Ensuring that the patient’s food is minced is another recommended practice for patients with Huntington’s disease. Minced food is easier to chew and swallow, which can help prevent choking and aspiration.

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Correct Answer is A

Explanation

Choice A rationale
Facial droop is a classic symptom of stroke. It occurs when there’s weakness or paralysis on one side of the face, which is caused by a disruption in the nerve signals due to a stroke. This can be easily observed in the person’s smile, as it will appear uneven.
Choice B rationale
While dysrhythmias can be associated with stroke, they are not the most indicative symptom. Dysrhythmias are more commonly associated with heart conditions.
Choice C rationale
Periorbital edema, or swelling around the eyes, is not typically a symptom of stroke. It can be caused by various conditions such as allergies, infections, or kidney problems.

Choice D rationale
Projectile vomiting is not typically a symptom of stroke. It can be caused by various conditions such as gastrointestinal issues, brain tumors, or increased intracranial pressure.

A. Support the right arm with a sling or pillow to prevent shoulder dislocation. B. Anticipate the client will exhibit some degree of expressive or receptive aphasia. C. Place the wheelchair on the client’s left side when transferring him into a wheelchair. D. Provide close supervision because of the client’s impulsiveness and poor judgment.

Correct Answer is D

Explanation

Choice A rationale
Supporting the right arm with a sling or pillow can help prevent shoulder dislocation, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice B rationale
While it is true that a patient who has experienced a stroke in the right hemisphere of the brain may exhibit some degree of expressive or receptive aphasia, anticipating this does not directly ensure the patient’s safety.
Choice C rationale

Placing the wheelchair on the client’s left side when transferring him into a wheelchair is a good practice, but it may not directly ensure the safety of a patient who has experienced a stroke in the right hemisphere of the brain.
Choice D rationale
Patients who have experienced a stroke in the right hemisphere of the brain often exhibit impulsiveness and poor judgment. Therefore, providing close supervision can help ensure the patient’s safety.

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The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch. What action by the new nurse would cause the precepting nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is conducting an assessment on a patient suspected of having a stroke. Which assessment finding is most indicative of a stroke?

Correct Answer is A

Explanation

The nurse is caring for a client who experienced a stroke in the right hemisphere of the brain. What should the nurse do to ensure the safety of the patient?

Correct Answer is D

Explanation

The nurse is assessing a patient with a suspected stroke. What assessment finding is most suggestive of a stroke?

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The nurse is precepting a new nurse who is caring for a patient with a history of Huntington’s disease. The new nurse is preparing to feed the patient lunch.
What action by the new nurse would cause the precepting nurse to intervene?