The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Places food on the unaffected side of the mouth.

Raises the head of the bed to 80 degrees.

Positions the head with the chin tilted slightly downward.

Allows 30 minutes of rest before feeding.

Answer and Explanation

The Correct Answer is B

A. Placing food on the unaffected side of the mouth is appropriate for a client who has had a CVA and may have unilateral weakness. This technique helps the client chew and swallow effectively, reducing the risk of aspiration.

B. Raising the head of the bed to 80 degrees is too high and can increase the risk of choking or aspiration by making it harder for the client to control the food bolus during swallowing. A more appropriate position is raising the head of the bed to 45–60 degrees, which facilitates safe swallowing while maintaining comfort. This action requires additional teaching.

C. Positioning the head with the chin tilted slightly downward, known as the chin-tuck position, is a recommended strategy to prevent aspiration. This position helps close the airway during swallowing, reducing the risk of food or liquid entering the trachea.

D. Allowing 30 minutes of rest before feeding is appropriate because it ensures the client is not fatigued, which can compromise swallowing ability and increase the risk of aspiration.

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Correct Answer is B

Explanation

To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus.

Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.

Choice A is not the answer because tapping the feet forwards and backwards exercises the ankle joint, which is not a hinge joint.

Choice C is not the answer because turning the head to the right and left exercises the pivot joint in the neck, which is not a hinge joint.

Choice D is not the answer because extending the arm at the side and rotating in circles exercises the ball-and-socket joint in the shoulder, which is not a hinge joint.

A. Solid with red streaks. B. Formed but soft. C. Brown liquid. D. Tarry appearance. E. Multiple hard pellets.

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

Explanation

A. Solid stool with red streaks may indicate lower gastrointestinal bleeding and requires further evaluation.
B. Formed but soft stool is a normal finding and does not require follow-up.
C. Brown liquid stool may suggest diarrhea or malabsorption issues, warranting further assessment.
D. A tarry appearance can indicate upper gastrointestinal bleeding and requires prompt follow-up.
E. Multiple hard pellets may indicate constipation or dehydration and should be addressed.

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The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Nursing Test Bank

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The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

Correct Answer is B

Explanation

Which descriptions of stool warrant additional follow-up by the nurse? (Select all that apply.).

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

Explanation

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The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration.
Which action by the UAP should the nurse recognize indicates the need for additional teaching?