Fundamentals Scenario: Vernon Russell | Questions with 100 % Correct Answers | Verified

A patient with dysphagia following a stroke expresses concern about having difficulty eating and drinking. What is the appropriate reply by the nurse? - CORRECT ANSWERMuscle weakness frequently occurs after a stroke; we need to make sure that food is not going into your lungs. Rationale: The appropriate reply by the nurse would be to explain that muscle weakness frequently occurs after a stroke. Making sure the GI tract is functioning would be an appropriate action to take after surgery. Telling the patient to ask the provider is inappropriate because the nurse is able to answer this question. Although the patient may seem worried, the question is specifically about patient teaching rather than therapeutic communication. The appropriate reply by the nurse would be to answer the patient's question When taking a patient's health history, which of the following does the nurse identify as risk factors for having a stroke? (Select all that apply.) - CORRECT ANSWER-- Hypertension - Smoking - Diabetes Mellitus Rationale: Risk factors for stroke include hypertension, smoking, and diabetes. Obesity, not weight loss, is a risk factor for stroke. Asthma is not a risk factor for stroke The nurse is caring for a patient who is suspected of having a stroke. What should be the nurse's first action to ensure patient safety when it appears the patient is having difficulty swallowing prescribed oral medication? pg. - CORRECT ANSWERHold this dose of medication and make the patient NPO. Rationale: Difficulty swallowing may lead to aspiration. The nurse's first action should be to hold the medication dose and make the patient nothing by mouth (NPO). The nurse should then notify the provider, who will probably order a swallow study; this, however, is not the first action because patient safety is the priority. Educating the patient is an appropriate intervention but does not address the immediate issue of patient safety The nurse is caring for four medical-surgical patients. Which patient should be assessed using the Glasgow Coma Scale? pg. 733 - CORRECT ANSWER-A 47-year-old patient who suffered a brain injury and lost consciousness in a motor vehicle accident.Rationale: The correct answer is a 47-year-old patient who suffered a brain injury and lost consciousness in a motor vehicle accident. The Glasgow Coma Scale measures Eye Opening, Verbal Response, and Motor Response and is typically used with patients who have suffered a brain injury as a result of trauma. The 32-year-old patient who is paraplegic was hospitalized for pneumonia, not a brain injury. The patient with cancer who has anxiety and depression nor the older adult patient with dementia did not experience a brain injury