Before feeding a patient four days following a stroke, what should the nurse do first?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Check the patient's gag reflex. This is the priority action before feeding a patient four days following a stroke because assessing the patient's ability to protect their airway is crucial to prevent aspiration, especially in the acute phase post-stroke when swallowing reflexes may be impaired. Option B) Order a soft diet for the patient is incorrect because before diet modifications can be made, assessing the patient's gag reflex and ability to swallow safely is essential. Option C) Raise the head of the bed to a sitting position is not the first action because it does not directly address the risk of aspiration when feeding a stroke patient. Option D) Evaluate the patient's ability to swallow small amounts of crushed ice or ice water is not the initial step as assessing the gag reflex is more comprehensive and directly related to the patient's safety during feeding. In an educational context, understanding the importance of assessing the gag reflex in stroke patients is crucial for nurses in providing safe and effective care. This knowledge helps prevent complications such as aspiration pneumonia, which can have serious consequences for patients. Nurses must prioritize airway protection and swallowing function assessments in stroke patients to ensure their well-being and recovery.

Correct Answer: B

Rationale: The correct answer to the question regarding the distressing problem experienced by a patient with ALS being the retention of cognitive function with total degeneration of motor function (Option B) is due to the nature of ALS, also known as Amyotrophic Lateral Sclerosis or Lou Gehrig's disease. ALS is a progressive neurodegenerative disease that primarily affects the motor neurons in the brain and spinal cord, leading to the loss of voluntary muscle control. In ALS, the cognitive function of the patient remains intact while the motor function deteriorates over time. This creates a distressing situation for the patient as they are fully aware of their physical decline and loss of independence, which can be emotionally challenging and frustrating. Option A, painful spasticity of the face and extremities, is not the most distressing problem in ALS, as pain is a symptom that can be managed with medications and therapies. Option C, uncontrollable writhing and twisting movements of the face and limbs, is more characteristic of conditions like Huntington's disease, not ALS. Educationally, understanding the specific challenges and symptoms associated with ALS is crucial for healthcare providers to provide appropriate care and support for patients with this condition. Recognizing the unique emotional and physical struggles faced by ALS patients can guide healthcare professionals in developing comprehensive care plans to improve the quality of life for these individuals.

Correct Answer: B

Rationale: The correct answer is B) The caregiver is manifesting symptoms of caregiver role strain. This is the correct answer because caregiver role strain refers to the physical, emotional, and mental exhaustion experienced by caregivers due to the demands of caregiving. Recognizing caregiver role strain is crucial as it can impact both the caregiver's well-being and their ability to effectively care for the patient. Option A is incorrect because developing signs of Alzheimer's disease (AD) in the caregiver is not indicated in the question and is not a typical assessment finding related to caregiver stress. Option C is incorrect as it simply suggests a need for a break without specifically addressing the caregiver's stress and role strain. Option D is incorrect because while involving other family members in the patient's care may be beneficial, it does not address the caregiver's current state of caregiver role strain. In an educational context, it is important for nurses to be able to recognize and assess caregiver role strain as part of holistic patient care. By identifying caregiver stress, nurses can provide support and resources to help caregivers cope with the challenges of caregiving and maintain their own well-being.

Correct Answer: A

Rationale: In the presence of compartment syndrome, the correct surgical treatment that the nurse should prepare the patient for is option A) Fasciotomy. Compartment syndrome is a serious condition that occurs when increased pressure within a muscle compartment compromises blood flow and can lead to tissue damage and necrosis. A fasciotomy involves making an incision through the fascia to relieve the pressure within the compartment, allowing for improved blood flow and preventing further tissue damage. Option B) Amputation is not the primary surgical treatment for compartment syndrome. Amputation is usually considered as a last resort when tissue damage is extensive and irreversible. Option C) Internal fixation is a surgical procedure used to stabilize fractured bones with hardware such as screws, plates, or rods. While internal fixation may be needed for fractures, it is not the primary treatment for compartment syndrome. Option D) Release of tendons is not the appropriate surgical treatment for compartment syndrome. Tendons are not the primary issue in compartment syndrome; it is the increased pressure within the muscle compartment that needs to be addressed. In an educational context, understanding the appropriate interventions for compartment syndrome is crucial for nurses and healthcare providers working in acute care settings. Prompt recognition of compartment syndrome and knowledge of the appropriate interventions are essential to prevent further tissue damage and preserve limb function. This question reinforces the importance of surgical interventions in managing compartment syndrome and highlights the critical role of nurses in preparing patients for such procedures to optimize outcomes and prevent complications.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Assess the incision for hemorrhage. This is the priority nursing intervention because postoperative hemorrhage can be a life-threatening complication following amputation surgery. By assessing the incision site for any signs of bleeding, the nurse can quickly identify and address any potential issues, ensuring the patient's safety and well-being. Option A) Monitor the patient's vital signs is important, but in this specific situation, assessing for hemorrhage takes precedence due to its immediate threat to the patient's life. Option C) Elevate the residual limb on pillows is a good measure to reduce swelling and promote circulation, but it is not the most critical intervention in the immediate postoperative period. Option D) Having the patient flex and extend the knee every hour is important for promoting circulation and preventing complications like contractures, but it is not the priority immediately after surgery when assessing for hemorrhage is crucial. In an educational context, understanding the priority of nursing interventions postoperatively is crucial for providing safe and effective care to patients. By prioritizing assessments and interventions based on the patient's condition and potential risks, nurses can ensure optimal outcomes and prevent complications.