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 D
Explanation
Choice A reason: Recommending a total fat intake of 12 g each day is not an appropriate action for the nurse to take because it is too low for most adults. The recommended dietary allowance (RDA. for fat is 20 to 35% of total calories per day, which translates to about 44 to 78 g of fat per day for an average adult who consumes 2,000 calories per day.
Choice B reason: Referring the client to a weight-loss support group is not an appropriate action for the nurse to take because the client does not need to lose weight. A body mass index (BMI) of 22 is within the normal range, which is 18.5 to 24.9. A weight-loss support group is more suitable for clients who have a BMI of 25 or higher, which indicates overweight or obesity.
Choice C reason: Advising the client to add 500 calories per day to the diet is not an appropriate action for the nurse to take because it may lead to weight gain. A client who has a BMI of 22 does not need to increase their caloric intake unless they have other medical conditions or nutritional needs that require more calories. Adding 500 calories per day to the diet can result in gaining about one pound per week, which can increase the risk of obesity and its complications.
Choice D reason: Encouraging the client to continue current daily caloric intake is an appropriate action for the nurse to take because it can help maintain a healthy weight. A client who has a BMI of 22 has a balanced energy intake and expenditure, which means that they consume enough calories to meet their metabolic needs and physical activity level. Continuing current daily caloric intake can prevent weight loss or gain and promote health and wellness.
Correct Answer is C
Explanation
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
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