Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

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Question 1 of 5

Following a CVA, the nurse assesses that a client has developed dysphagia, hypoactive bowel sounds, and a firm, distended abdomen. Which prescription for the client should the nurse question?

Correct Answer: A

Rationale: The correct answer is A: Continuous tube feeding at 65 ml/hr via gastrostomy. After a CVA, dysphagia, hypoactive bowel sounds, and a firm, distended abdomen indicate a risk for aspiration and bowel obstruction. Continuous tube feeding may worsen these issues. Option B provides nutrition intravenously, bypassing the gastrointestinal tract. Option C helps decompress the stomach. Option D is a medication to help with GI motility. Therefore, the nurse should question option A due to the risk of complications post-CVA.

Question 2 of 5

While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

Correct Answer: D

Rationale: The correct answer is D because deep inflamed cracks at the corners of the mouth can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). Ensuring the client gets adequate B vitamins through foods or supplements can help address the deficiency and improve the condition. Option A is incorrect as simply applying a moisturizing cream does not address the underlying cause. Option B is not the best choice because while vitamin B-rich foods are beneficial, they may not be sufficient to correct a deficiency. Option C is not the immediate priority unless there are other concerning symptoms present.

Question 3 of 5

A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?

Correct Answer: C

Rationale: The correct answer is C: "You are upset that this incident has brought you here." This response acknowledges the client's feelings of anger and validates her emotions, showing empathy and understanding. It demonstrates active listening and therapeutic communication, which is crucial in building trust and rapport with the client. Choice A is incorrect as it dismisses the client's feelings of anger and invalidates her emotions by shifting the focus to being grateful instead. Choice B is incorrect as it minimizes the client's emotional response by focusing on the material aspect of the situation rather than addressing her feelings. Choice D is incorrect as it does not address the client's emotional state and is a closed-ended question that does not encourage further discussion or exploration of the client's feelings.

Question 4 of 5

When should surgical correction of hypospadias typically occur for a newborn infant as advised by the nurse?

Correct Answer: B

Rationale: The correct answer is B because surgical correction of hypospadias is typically recommended before the child is potty-trained. This is important for optimal cosmetic and functional outcomes, as the procedure is more straightforward in infants due to their smaller anatomy. Delaying the surgery can lead to increased risk of complications and potential psychological impact on the child as they grow older. A: Repair within one month to prevent bladder infections is not the primary reason for early correction of hypospadias. C: Delaying the repair to school age for reducing castration fears is not a valid reason for postponing the surgery. D: Waiting until after sexual maturity to form a proper urethra repair is not recommended as early correction typically yields better results.

Question 5 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer: C

Rationale: The correct answer is C: Oxygen saturation of 88%. In COPD patients, low oxygen saturation indicates inadequate gas exchange and potential respiratory distress. Oxygen saturation below 90% requires immediate intervention to prevent hypoxemia. A: Barrel-shaped chest is a common finding in COPD due to hyperinflation, but it is not a critical indicator of acute exacerbation. B: Use of accessory muscles suggests increased work of breathing but may not be as urgent as low oxygen saturation. D: Respiratory rate is within normal range, so it is less concerning than the low oxygen saturation.

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