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: Dry eyes are not caused by vitamin D deficiency, but by other factors such as aging, medication, environmental conditions, or eye diseases. Vitamin D does not have a direct role in eye health or function.
Choice B reason: Fractures are caused by vitamin D deficiency, as vitamin D helps the body absorb calcium, which is essential for bone health and strength. Vitamin D deficiency can lead to osteoporosis, a condition in which the bones become brittle and prone to breaking.
Choice C reason: Infection is not caused by vitamin D deficiency, but by other factors such as exposure to pathogens, weakened immune system, or poor hygiene. Vitamin D may have some role in modulating immune responses, but it is not a primary factor in preventing infection.
Choice D reason: Swelling is not caused by vitamin D deficiency, but by other factors such as injury, inflammation, fluid retention, or allergic reaction. Vitamin D does not have a direct role in regulating fluid balance or reducing inflammation.
Correct Answer is A
Explanation
Choice A reason: Tuna fish is a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is soft, moist, and easy to swallow. Tuna fish also provides protein, omega-3 fatty acids, and vitamin D for the client.
Choice B reason: Roast beef is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has missing teeth. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
Choice C reason: Apple slices are not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are crisp, firm, and sticky. Apple slices can cause irritation or injury to the gums or mouth or dislodge any remaining teeth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Choice D reason: Dried fruit is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are chewy, sticky, and sugary. Dried fruit can adhere to the gums or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
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