While providing oral medications to a patient recovering from a stroke, the nurse notices that the patient coughs repeatedly and has difficulty clearing the throat. What should the nurse do?
1. Change the diet to full liquid.
2. Change the diet to soft.
3. Request a physical therapy consult.
4. Request a swallowing evaluation by speech therapy.
4
Rationale 1: This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient, such enteral or parenteral routes.
Rationale 2: This patient needs to be made NPO immediately. A nutritional consult needs to be done in order to determine an alternative means of providing nutrition for this patient.
Rationale 3: A PT consult would be done but it would be for promoting mobility and preventing muscle atrophy.
Rationale 4: Dysphagia, or difficulty swallowing, is very common post stroke and is a major risk factor for developing aspiration pneumonia. The nurse should keep the patient NPO and ask for a speech therapy order for a swallowing evaluation.
You might also like to view...
The healthcare provider prescribes aripiprazole (Abilify) for the client with schizophrenia. Which is the priority outcome for the client?
A) The client will report a decrease in auditory hallucinations. B) The client will report symptoms of restlessness. C) The client will consume adequate fluids and a high-fiber diet. D) The client will be compliant with taking the medication as prescribed.
Which observations, if documented in the medical record, would indicate that the treatment plan of a
severely depressed client has been effective? a. "Slept 6 hours uninterrupted, sang with activity group, anticipates seeing grandchild.". b. "Slept 10 hours, attended craft group, stated his "project is a mess, just like me.". c. "Slept 5 hours, personal hygiene adequate with assistance, weight loss of 1 pound.". d. "Slept 7 hours, states he feels tired all the time, preoccupied with perceived inadequacies.".
What is the best response by the nurse when explaining biofeedback to a client?
A) "It is a spiritual practice that combines exercise with mental focus." B) "It is beneficial in expressing feelings." C) "It allows a reduction of symptoms through voluntary control measures." D) "It requires the use of machines in a controlled environment."
A patient has developed an infection and is taking metformin. How will the infection change his diabetic regimen?
A) Metformin is contraindicated in the presence of an infection. B) Metformin will be given more frequently to decrease blood sugar. C) Metformin will result in better regulation of blood sugar. D) Metformin will allow the patient to decrease the absorption of glucose.