Which of the following nutritional therapies should the nurse expect to include in the plan of care?
NPO until dysphagia subsides.
Initiation of total parenteral nutrition.
Mechanical soft diet.
Supplements via NG tube.
The Correct Answer is C
Choice A rationale
NPO (nothing by mouth) until dysphagia subsides might be a temporary measure immediately following a stroke to prevent aspiration. However, prolonged NPO status can lead to malnutrition and dehydration. The plan of care should aim for the safest and most effective route for nutritional support as soon as feasible, considering the patient's swallowing ability.
Choice B rationale
Initiation of total parenteral nutrition (TPN) is a method of providing nutrition intravenously, bypassing the gastrointestinal tract. TPN is typically reserved for patients with a non-functional or severely impaired digestive system. For a patient with dysphagia after a stroke, if the gastrointestinal tract is functional, enteral feeding (via a feeding tube) is often preferred over TPN due to its physiological benefits and lower risk of complications.
Choice C rationale
A mechanical soft diet consists of foods that are easy to chew and swallow. The texture of the food is altered (e.g., pureed, mashed, ground) to reduce the effort required for mastication and swallowing, thereby decreasing the risk of aspiration in patients with dysphagia. This type of diet is a common nutritional therapy for individuals with mild to moderate swallowing difficulties following a stroke.
Choice D rationale
Supplements via NG tube (nasogastric tube) involve delivering liquid nutritional formulas directly into the stomach through a tube inserted into the nose and down the esophagus. While an NG tube can provide necessary nutrition for patients with dysphagia, a gastrostomy tube (G-tube or PEG tube), placed directly into the stomach through the abdominal wall, is often preferred for long-term enteral feeding as it is generally more comfortable and less likely to cause irritation than an NG tube.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While mammography is a crucial tool for detecting breast cancer, particularly in women over 40, it is not a replacement for breast self-examination (BSE). Mammograms are radiographic images that can detect abnormalities, but BSE helps women become familiar with their own breasts and identify changes that may occur between mammograms.
Choice B rationale
Although annual clinical breast exams by a physician are important, they are not a substitute for monthly BSE. BSE allows women to regularly assess their breasts for any new lumps, changes in size or shape, skin thickening, or nipple discharge. These changes might occur between annual physician visits.
Choice C rationale
Mammograms are indeed effective in detecting breast cancer, often before a lump can be felt. However, BSE plays a vital role in increasing a woman's awareness of her breasts' normal texture and appearance. This familiarity enables her to notice subtle changes that may warrant further medical evaluation, complementing the benefits of mammography.
Choice D rationale
Mammograms are a highly reliable method for detecting breast cancer, especially in early stages. However, BSE is not unnecessary. It empowers women to take an active role in their breast health by promoting early detection of changes that might be indicative of cancer and can occur between scheduled mammograms.
Correct Answer is C
Explanation
Choice A rationale
Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.
Choice B rationale
Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.
Choice C rationale
Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.
Choice D rationale
Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.
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