A nurse is caring for a client who had a stroke and is drooling. Which of the following actions should the nurse take first?
Offer the client thickened liquids to drink.
Monitor the client for indications of fatigue during meals.
Check the client's gag reflex.
Monitor the client's ability to speak consistently.
The Correct Answer is C
A. Offer the client thickened liquids to drink: Offering thickened liquids can help reduce the risk of aspiration in clients with dysphagia, which is common after a stroke. However, this should be done after confirming that the client has a safe swallowing mechanism, such as an intact gag reflex. Administering liquids before assessing swallowing safety can increase the risk of aspiration pneumonia.
B. Monitor the client for indications of fatigue during meals: Fatigue can compromise the client’s ability to chew and swallow effectively, increasing the risk of aspiration. Monitoring for this is important but is not the immediate priority when the client is already drooling, a sign that they may be unable to manage their oral secretions. Ensuring safe swallowing should be addressed before monitoring meal-time fatigue.
C. Check the client's gag reflex: Checking the gag reflex is the most important initial action because it directly assesses the client’s ability to swallow safely. Drooling after a stroke often indicates impaired neuromuscular control, which puts the client at high risk for aspiration. The gag reflex gives immediate information on whether oral intake is safe.
D. Monitor the client's ability to speak consistently: Monitoring speech consistency can provide insights into neurological recovery and motor control, but it is not the first concern in a drooling stroke patient. The primary danger is aspiration due to impaired swallowing. Speaking ability does not directly reflect swallowing safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Avoid feeding the infant more than once every 3 hr: Newborns should be fed on demand, which typically occurs every 1-3 hours, but it can vary. Some babies may want to nurse more frequently, especially in the early days, for comfort or to stimulate milk production. Restricting feedings to a set time interval can hinder the infant's ability to receive enough nourishment.
B. Provide the newborn with 15 mL of sterile water each day: Breast milk or formula provides all the hydration and nutrition the infant needs. Offering water can interfere with the infant's intake of breast milk, which is essential for proper growth and development.
C. Store expressed milk in the refrigerator for up to 7 days: While expressed breast milk can be stored in the refrigerator, the recommended storage time is typically 3-5 days, not 7 days. Storing milk for longer periods may increase the risk of bacterial growth, which could compromise the milk's safety and quality.
D. Feedings should begin within 1 hour after birth: Initiating breastfeeding within the first hour after birth is critical for both mother and baby. Early initiation of breastfeeding helps establish a good milk supply, promotes bonding, and provides the newborn with colostrum, which is rich in antibodies and nutrients essential for the baby’s immune system and overall health.
Correct Answer is B
Explanation
A. Fortified cereals: Fortified cereals are a good source of non-heme iron, which is iron added during processing and derived from plant sources or synthetic compounds. While helpful in increasing iron intake, non-heme iron is not absorbed as efficiently by the body compared to heme iron found in animal-based foods.
B. Ground beef: Ground beef is a rich source of heme iron, which is derived from animal hemoglobin and myoglobin. Heme iron is better absorbed by the human body than non-heme iron, making it particularly beneficial for pregnant clients who have increased iron needs to support fetal development and increased blood volume.
C. Kale: Kale contains non-heme iron, as it is a plant-based food. While it contributes to overall iron intake and is nutritionally valuable, the form of iron in kale is less readily absorbed by the body, especially in the absence of vitamin C, which enhances non-heme iron absorption.
D. Lima beans: Lima beans also provide non-heme iron, similar to other legumes and plant-based sources. Though they can support iron intake, they are not considered a source of heme iron and therefore do not offer the same absorption efficiency as animal-based options like meat.
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