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 B

Explanation

A. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.

B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.

C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.

D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.

A. Normal pessimism of the elderly. B. A cry for sympathy. C. Normal grieving. D. Evidence of high suicide potential.

Correct Answer is D

Explanation

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following assessment findings is observed in a client with opiate use?

Correct Answer is B

Explanation

A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Correct Answer is D

Explanation

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

A client with alcoholism has just completed a residential treatment program. What can this client reasonably expect?

A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to:

A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit:

A psychiatric mental-health nurse is evaluating the treatment plan of an adult client diagnosed with schizophrenia disorder with aggressive behaviors. Which outcome of the client would demonstrate successful treatment?

When administering an antipsychotic medication to a client diagnosed with schizophrenia, which action would be most appropriate for the nurse to include in the client's plan of care? Select all that apply.

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

Building trust is especially critical to developing a therapeutic relationship with an anxious client. Which of the following interventions contributes to this trust?