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 B

Explanation

Choice A rationale
While hypertension is a risk factor for stroke, it is a modifiable risk factor. This means it can be controlled and managed through lifestyle changes and medication.
Choice B rationale
Family history is a non-modifiable risk factor for stroke. If a close family member, like a parent or sibling, has had a stroke, a person’s risk of stroke is slightly higher.
Choice C rationale
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice D rationale
Obesity is a modifiable risk factor for stroke. Maintaining a healthy weight through diet and regular exercise can help reduce the risk of stroke.

A. Assessing the patient’s ability to follow complex commands B. Assessing the patient’s judgment C. Assessing the patient’s verbal response D. Assessing the patient’s response to pain

Correct Answer is D

Explanation

Choice D rationale
When assessing a patient with an altered level of consciousness, the nurse’s initial action should be to assess the patient’s response to pain. This is a fundamental part of the neurological examination and can provide valuable information about the patient’s level of consciousness and neurological function. Pain response can be assessed by applying a painful stimulus, such as a pinch, and observing the patient’s reaction.
Choice A rationale
Assessing the patient’s ability to follow complex commands is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. This assessment requires a higher level of cognitive function and may not be possible in a patient with significantly altered consciousness.
Choice B rationale
Assessing the patient’s judgment is an important part of the mental status examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. Like the ability to follow complex commands, judgment requires a higher level of cognitive function and may not be assessable in a patient with significantly altered consciousness.

Choice C rationale
Assessing the patient’s verbal response is an important part of the neurological examination, but it is not typically the initial action when assessing a patient with an altered level of consciousness. The patient’s ability to speak and the content of their speech can provide important information about their neurological function, but this assessment may not be possible in a patient with significantly altered consciousness.

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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

A nurse is teaching a group of older adults about risk factors for developing a stroke. Which non-modifiable risk factors should the nurse include in the teaching?

Correct Answer is B

Explanation

The nurse is caring for a patient whose recent health history includes an altered level of consciousness. What should be the nurse’s initial action when assessing this patient?

Correct Answer is D

Explanation

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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?