A nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following actions should the nurse take when assisting the client to eat?
Offer meals to the client following physical activity.
Provide peanut butter on crackers as a snack choice.
Provide liquids in a cup with a straw.
Instruct the client to tilt his head forward when swallowing.
The Correct Answer is D
A. Offer meals to the client following physical activity: This is incorrect as eating after physical activity might be challenging for a client with dysphagia, and it is better to provide meals when the client is at rest.
B. Provide peanut butter on crackers as a snack choice: This is incorrect because peanut butter and crackers might be difficult to swallow and could pose a choking risk for someone with dysphagia.
C. Provide liquids in a cup with a straw: This is incorrect as straws can cause liquids to be aspirated more easily, which is a risk for clients with dysphagia.
D. Instruct the client to tilt his head forward when swallowing: This is correct because tilting the head forward can help prevent aspiration and facilitate safer swallowing in clients with dysphagia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Knee-high stockings can be rolled down slightly to provide comfort": Rolling down antiembolic stockings can cause bunching and reduce their effectiveness in preventing deep vein thrombosis. They should fit smoothly without rolling.
B. "I should flex my toes when applying the stockings": To apply the stockings, the toes should be pointed or relaxed, not flexed, to ensure proper application and avoid discomfort.
C. "The thigh-high stockings should reach just above the gluteal folds": This is correct as thigh-high stockings should extend to just above the gluteal folds to ensure proper fit and effectiveness in preventing blood clots.
D. "I should reapply the stockings before I get out of bed": Antiembolic stockings are typically applied in the morning after getting out of bed and should remain on throughout the day. Reapplying before getting out of bed is not necessary.
Correct Answer is A
Explanation
A. Dyspnea: This is correct as dyspnea (difficulty breathing) can be a sign of fluid overload, particularly when excess fluid accumulates in the lungs.
B. Pruritus: This is more indicative of an allergic reaction rather than fluid overload.
C. Fever: This is often associated with transfusion reactions or infection, not specifically fluid overload.
D. Bradycardia: This is less commonly associated with fluid overload and more often seen in other conditions or complications.
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