The patient was admitted with the diagnosis of a stroke. The ...

[piesebel]

The patient was admitted with the diagnosis of a stroke. The patient experiences dysphagia and right side paralysis and needs assistance with activities of daily living (ADLs).
 
  The nurse caring for the patient has assigned the task of feeding the patient to the new nursing assistant personnel (NAP), and is concerned about aspiration. The nurse knows additional teaching is necessary when NAP states which of the following? a. I will remind the patient to tilt the head backward when drinking fluids.
  b. Thin fluids like water and fruit juice will need to be thickened.
  c. I need to watch for pocketing food as I feed the patient.
  d. It will take much longer to feed the patient than it did before the stroke.

Question 2

A 36-year-old African-American patient has been admitted to the hospital with diabetic ketoacidosis. The nurse who is admitting him notes that his blood pressure is 164/98 . Which of the following should the nurse do next?
 
  a. Call the health care provider because the patient's values differ from the standard range.
  b. Immediately call the health care provider and request antihypertensive medication.
  c. Ask the patient what his blood pressure normally measures for comparison.
  d. Do nothing; this is within a normal range for a patient with diabetic ketoacidosis.

[jojobee318]

Answer to Question 1

A
Remind the patient to not tilt head backward when eating or while drinking because this may cause food and liquid to be misdirected into the airway. Thin liquids such as water and fruit juice are difficult to control in the mouth and pharynx and are more easily aspirated so these need to be thickened. It will take much longer to feed and pocketing food are both correct.

Answer to Question 2

C
Know the patient's usual range of vital signs. A patient's usual values sometimes differ from the standard range for that age or physical state. Use the patient's usual values as a baseline for comparison with findings taken later. A single measurement does not adequately reflect a patient's blood pressure. Blood pressure trends, not individual measurements, guide your nursing interventions. Hypertension is defined as systolic blood pressure (SBP) greater than 140 mm Hg, diastolic blood pressure (DBP) greater than 90 mm Hg