a patient recovering from a stroke has difficulty swallowing which action should the nurse prioritize

ATI RN

ATI Capstone Comprehensive Assessment B

1. A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?

A. Begin feeding the patient soft solids.
B. Place the patient on NPO (nothing by mouth) status.
C. Provide ice chips to help soothe the throat.
D. Start the patient on a clear liquid diet.

Correct answer: B

Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.

2. What is the priority intervention for a patient experiencing chest pain?

A. Administer nitroglycerin as prescribed.
B. Encourage the patient to take deep breaths.
C. Monitor the patient's blood pressure closely.
D. Encourage the patient to rest in a comfortable position.

Correct answer: A

Rationale: The correct answer is to administer nitroglycerin as prescribed. Nitroglycerin helps relieve chest pain by dilating blood vessels and improving blood flow, addressing the immediate concern of chest pain. Encouraging deep breaths may not be appropriate for chest pain, monitoring blood pressure, although important, is not the priority when the patient is experiencing chest pain, and while resting in a comfortable position is beneficial, administering nitroglycerin is the priority intervention to address the chest pain.

3. What is the most appropriate method for assessing a patient's pain level?

A. Observe the patient's facial expressions.
B. Use a standardized pain scale, such as 0-10.
C. Ask the patient to rate their pain based on their mood.
D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

4. A family was referred to crisis intervention services after a natural disaster. One family member refuses to attend, stating, 'No way, I'm not crazy.' What is the nurse's best response?

A. Don't worry now. The psychiatrists are well trained to help.
B. Many times, disasters can create mental health problems, so you really should participate with your family.
C. This will help your family communicate better.
D. Seeking this kind of help does not mean that you have a mental illness; it is a short-term problem-solving technique.

Correct answer: D

Rationale: The nurse should reassure the family member that seeking help does not imply mental illness, but is part of coping with the disaster.

5. When working with a client who does not speak the same language, which of the following actions should the nurse take?

A. Speak directly to the interpreter
B. Use family members to translate
C. Speak directly to the patient
D. Use medical jargon

Correct answer: C

Rationale: When caring for a client who does not speak the same language, it is essential for the nurse to speak directly to the patient. This approach helps maintain rapport, establishes a trusting relationship, and ensures better communication. Speaking to the interpreter instead of the patient can lead to misunderstandings and hinder the therapeutic relationship. Using family members to translate is not recommended as they may not provide accurate or confidential information. Lastly, using medical jargon can further complicate communication and may not be understood by the patient.