A nurse is caring for a client who had a stroke and has manifestations of dysphagia. Which of the following interventions should the nurse take?
Use liquids to clear food from the client's mouth.
Tilt the client's head backwards to facilitate swallowing.
Add a thickening agent to liquids.
Place the client in a semi-Fowler's position.
The Correct Answer is C
Choice A reason: Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.
Choice B reason: Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.
Choice C reason: Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.
Choice D reason: Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Feedings should not be accompanied by nonnutritive sucking. Nonnutritive sucking is the act of sucking on a pacifier, finger, or other object without getting any nutrition. Nonnutritive sucking can interfere with the establishment of breastfeeding, cause nipple confusion, and reduce milk supply.
Choice B reason: Feedings should be on demand. On demand feeding means feeding the newborn whenever they show signs of hunger, such as rooting, sucking, or crying. On demand feeding helps the newborn regulate their appetite, meet their nutritional needs, and bond with their caregiver.
Choice C reason: Feedings should not begin within 1 hr after birth. This instruction is applicable for breastfeeding, not bottle feeding. Breastfeeding should begin within 1 hr after birth to initiate milk production, stimulate uterine contractions, and transfer colostrum to the newborn. Bottle feeding can be delayed until the newborn is stable and alert.
Choice D reason: Feedings may not occur in clusters. Cluster feeding means feeding the newborn more frequently and for longer periods of time during certain times of the day or night. Cluster feeding is common in breastfed newborns, especially during growth spurts or developmental leaps. Bottle fed newborns may not exhibit cluster feeding, as they tend to have more consistent and predictable feeding patterns.
Correct Answer is C
Explanation
Choice Areason: Graham crackers are made from wheat flour, which contains gluten. Peanut butter is a good source of fat and protein, but it may also contain traces of gluten from cross-contamination.
Choice Breason: Poached eggs are a good source of protein, but wheat bagel contains gluten, which is a protein found in wheat, barley, and rye. Gluten can damage the small intestine and cause malabsorption, diarrhea, and abdominal pain in people with celiac disease.
Choice C reason: Rice cereal is gluten-free and a good source of carbohydrates. Sliced bananas are gluten-free and a good source of potassium, fiber, and vitamin C.
Choice D reason: Rye toast contains gluten, which can harm people with celiac disease. Herbal tea is gluten-free and can help with hydration, but it does not provide enough calories or nutrients.
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