A 77-year-old female client experienced a stroke several weeks ago that has left her with several motor and sensory deficits, including dysphagia. The client is receiving a diet with a modified texture that is easier to chew and swallow. What nursing action should the nurse perform in order to maintain this client's safety during feeding?

Ensure that there is a complete and functional suction system at the bedside.

Position the head of the client's bed at a height of 30° to 45°.

Provide two larger meals each day rather than three smaller meals in order to prevent fatigue.

Encourage the client to hold her breath while she is attempting to swallow.

Answer and Explanation

The Correct Answer is A

A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.

B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.

C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.

D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.

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Correct Answer is D

Explanation

A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.

B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.

C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.

D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.

A. "Try to buy and consume as many organic and natural foods as you can." B. "Try to replace the complex carbohydrates in your diet with protein-rich foods." C. "Try to reduce the overall amount of fat that is in your diet." D. "If you eat four of five small meals each day, you'll find that you're able to reduce your calorie intake."

Correct Answer is C

Explanation

A. "Try to buy and consume as many organic and natural foods as you can." While organic and natural foods are generally healthy, this advice does not directly align with the DASH diet, which focuses more on nutrient balance and reduction of sodium, fats, and sugars.

B. "Try to replace the complex carbohydrates in your diet with protein-rich foods." The DASH diet emphasizes balanced intake of whole grains (complex carbohydrates), fruits, vegetables, and lean proteins, rather than replacing complex carbohydrates.

C. "Try to reduce the overall amount of fat that is in your diet." This recommendation is consistent with the DASH diet, which advises reducing saturated fats and total fat to help manage blood pressure.

D. "If you eat four of five small meals each day, you'll find that you're able to reduce your calorie intake." Eating smaller, more frequent meals may help with calorie control, but this advice is more related to weight management than directly aligning with the DASH diet's focus on nutrient-rich, heart-healthy foods.

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Naxlex Comprehensive Predictor Exams

Which of the following nursing interventions should a nurse perform when caring for a female client with mood disorder who is prescribed lithium?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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