A patient is having difficulty swallowing following a stroke, and a swallowing evaluation is ordered. The ff. nursing interventions might be recommended to help prevent aspiration during eating except:

Correct Answer: A

Rationale: Providing clear liquids only until the patient can swallow solid foods is not recommended as it restricts the patient's diet unnecessarily. In the case of difficulty swallowing after a stroke, it is important to modify the food consistency and provide appropriate techniques to support safe swallowing. Limiting the patient to clear liquids only could lead to inadequate nutrition and hydration. Instead, it is important to modify the diet consistency and use strategies such as altering the food presentation, having the patient swallow twice after each bite, placing food on the unaffected side of the mouth, and checking for pocketing of food to help prevent aspiration.

Correct Answer: C

Rationale: ACTH (Adrenocorticotropic hormone) might be ordered to help control symptoms of multiple sclerosis and possibly induce a remission. ACTH is sometimes used as a treatment option for multiple sclerosis due to its anti-inflammatory properties. It can help reduce inflammation in the central nervous system and, in some cases, lead to a decrease in symptoms and possibly induce a remission. However, it is important to note that ACTH is not commonly used as a first-line treatment for multiple sclerosis and is usually reserved for cases that are refractory to other medications.

Correct Answer: A

Rationale: In the presence of coma or unconsciousness, maintaining a clear airway is the major therapeutic measure to ensure adequate breathing and oxygenation. A clear airway is vital for the patient's survival and should be the priority to prevent respiratory distress or failure. Providing good nursing care is important for overall patient well-being, but ensuring a clear airway is crucial for immediate life support. Retention of a catheter is not a major therapeutic measure in the context of coma or unconsciousness unless specifically indicated for monitoring or treatment of underlying conditions. Therefore, the most critical intervention in this scenario is the maintenance of a clear airway.

Correct Answer: A

Rationale: The Snellen chart is a chart used to measure visual acuity. The numbers in a Snellen fraction indicate the distance from which a person with normal eyesight can see the letters on the chart. In the case of 20/80, this means that the person can see at 80 feet what a person with normal eyesight can see at 20 feet. So, option A is correct as it accurately explains what is indicated by a Snellen chart finding of 20/80.

Correct Answer: B

Rationale: Blurring of vision is typically the first symptom of a cataract that the nurse would expect a patient to report during assessment. As a cataract develops, it causes clouding of the eye's lens, leading to a decrease in the clarity of vision. This blurriness can progress over time, impacting the patient's ability to see clearly. Other symptoms such as glare sensitivity, poor night vision, double vision, and color fading may also be present as the cataract progresses. Dry eyes, eye pain, and loss of peripheral vision are not typically the initial symptoms associated with cataracts.