What should the nurse do to help the dysphagic patient? (Select all that apply.)
a. Sit the patient upright
b. Reduce distraction during mealtime
c. Offer fluid from a straw
d. Thicken liquids
e. Cue the patient to swallow
ANS: A, B, D, E
Offering fluids using a straw increases the possibility of choking or aspiration. All other options would be beneficial to the dysphagic patient.
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The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration. Which of the following findings are consistent with this condition? Standard Text: Select all that apply
1. Tenting noted on dorsal aspect of client's hand when skin turgor was assessed. 2. Client has produced 175 milliliters over the last 8 hours. 3. Dentures are loose, small sores noted in oral mucosa. 4. Healthcare provider notes client exhibiting xerostomia. 5. Client's apical heart rate is 82 beats per minute.
A patient with cancer is admitted with a weight loss of 25 lbs. over the last month with progressive anorexia. The nurse suspects this patient is experiencing what physiological effect of cancer?
1. anorexia–cachexia syndrome 2. paraneoplastic syndrome 3. infection 4. esophageal obstruction
A patient arrived at the emergency department after tripping over a rug and falling at home. Which finding is most important for the nurse to communicate to the health care provider?
a. There is bruising at the shoulder area. b. The patient reports arm and shoulder pain. c. The right arm appears shorter than the left. d. There is decreased shoulder range of motion.
The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.)
a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "What medications do you take?" e. "Is movement painful?" f. "Have you ever fallen?"