Nokea
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
- A. Firmly redirect the patients head when feeding.
- B. Administer phenothiazines after each meal as ordered.
- C. Encourage the patient to keep his or her feeding area clean.
- D. Apply deep, gentle pressure around the patients mouth to aid swallowing.
Correct Answer: D
Rationale: Deep, gentle pressure aids swallowing in Huntington's patients with choreiform movements. Redirecting the head or focusing on cleanliness is inappropriate, and phenothiazines are given before meals.
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A patient has been admitted to the neurologic unit for the treatment of a newly diagnosed brain tumor. The patient has just exhibited seizure activity for the first time. What is the nurses priority response to this event?
- A. Identify the triggers that precipitated the seizure.
- B. Implement precautions to ensure the patients safety.
- C. Teach the patients family about the relationship between brain tumors and seizure activity.
- D. Ensure that the patient is housed in a private room.
Correct Answer: B
Rationale: Safety during a seizure is the priority to prevent injury. Education, trigger identification, and room assignment are secondary actions.
The nurse is writing a care plan for a patient with brain metastases. The nurse decides that an appropriate nursing diagnosis is anxiety related to lack of control over the health circumstances. In establishing this plan of care for the patient, the nurse should include what intervention?
- A. The patient will receive antianxiety medications every 4 hours.
- B. The patients family will be instructed on planning the patients care.
- C. The patient will be encouraged to verbalize concerns related to the disease and its treatment.
- D. The patient will begin intensive therapy with the goal of distraction.
Correct Answer: C
Rationale: Encouraging verbalization helps the patient gain control over anxiety by understanding the disease and treatment. Routine medications or distraction do not address the root cause, and family planning does not empower the patient.
While assessing the patient at the beginning of the shift, the nurse inspects a surgical dressing covering the operative site after the patients cervical diskectomy. The nurse notes that the drainage is 75% saturated with serosanguineous discharge. What is the nurses most appropriate action?
- A. Page the physician and report this sign of infection.
- B. Reinforce the dressing and reassess in 1 to 2 hours.
- C. Reposition the patient to prevent further hemorrhage.
- D. Inform the surgeon of the possibility of a dural leak.
Correct Answer: D
Rationale: Serosanguineous drainage suggests a dural leak, a serious complication requiring surgical notification. It is not a direct sign of infection, and repositioning or reinforcing the dressing delays critical intervention.
A patient with Parkinsons disease is undergoing a swallowing assessment because she has recently developed adventitious lung sounds. The patients nutritional needs should be met by what method?
- A. Total parenteral nutrition (TPN)
- B. Provision of a low-residue diet
- C. Semisolid food with thick liquids
- D. Minced foods and a fluid restriction
Correct Answer: C
Rationale: Semisolid foods with thick liquids are easier to swallow, reducing aspiration risk. TPN, low-residue diets, or fluid restrictions are not indicated.
A patient with Huntington disease has just been admitted to a long-term care facility. The charge nurse is creating a care plan for this patient. Nutritional management for a patient with Huntington disease should be informed by what principle?
- A. The patient is likely to have an increased appetite.
- B. The patient is likely to require enzyme supplements.
- C. The patient will likely require a clear liquid diet.
- D. The patient will benefit from a low-protein diet.
Correct Answer: A
Rationale: Huntington's disease causes increased appetite due to involuntary movements, requiring high-calorie diets. Enzyme supplements, clear liquids, or low-protein diets are not indicated.