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. Place the client on his back, remove dangerous objects, and insert a bite block. Placing a client on their back during a seizure increases the risk of airway obstruction, and inserting a bite block is not recommended as it can cause injury.

B. Place the client on his side, remove dangerous objects, and insert a bite block. While positioning the client on their side is correct, inserting a bite block is contraindicated due to the risk of injury to the client.

C. Place the client on his back, remove dangerous objects, and hold down his arms. Restraining a client during a seizure is not recommended as it can cause injury. Placing the client on their back also poses a risk of airway obstruction.

D. Place the client on his side, remove dangerous objects, and protect his head. Positioning the client on their side helps maintain airway patency, removing dangerous objects prevents injury, and protecting the head helps prevent head trauma during the seizure.

A. "Inhalants are central nervous system (CNS) depressants similar to alcohol." B. "The 'high' that I am getting is from hallucinogenic properties in the inhalant" C. "Inhalants are easy to come by and highly addictive." D. "When inhaling solvents, I get an instant CNS stimulation that is euphoric.”

Correct Answer is C

Explanation

A. "Inhalants are central nervous system (CNS) depressants similar to alcohol." Inhalants are CNS depressants, but this response might not indicate full understanding of the risks and addictive nature of inhalants.

B. "The 'high' that I am getting is from hallucinogenic properties in the inhalant." This is incorrect because inhalants are not primarily hallucinogens; they depress the CNS, leading to effects similar to alcohol intoxication.

C. "Inhalants are easy to come by and highly addictive." This statement indicates the client understands the accessibility and addictive potential of inhalants, which is a critical aspect of the education provided by the nurse.

D. "When inhaling solvents, I get an instant CNS stimulation that is euphoric." While inhalants may provide a euphoric sensation, they are primarily CNS depressants, not stimulants. This response indicates a misunderstanding of their effects.

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Naxlex Comprehensive Predictor Exams

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

Correct Answer is D

Explanation

The nurse is caring for a client who has has been inhaling solvents to receive a "high." After the nurse provides education on the effects of inhaling solvents, which statement from the client indicates understanding of the teaching?

Correct Answer is C

Explanation

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