A nurse is caring for a client who had a stroke with left-sided paralysis and is at risk for dysphagia. Which of the following actions should the nurse take?
Elevate the head of the client's bed.
Use a syringe to give the client fluids.
Instruct the client to chew on the left side of their mouth.
Instruct the client to swallow with their head tilted back.
The Correct Answer is A
Choice A reason: Elevating the head of the client's bed can help prevent aspiration and facilitate swallowing. The nurse should keep the client's head elevated at least 30 degrees during and after feeding, and check for signs of aspiration, such as coughing, choking, or wheezing.
Choice B reason: Using a syringe to give the client fluids is not a safe method, as it can cause the fluids to enter the airway too quickly and cause aspiration. The nurse should use a spoon or a cup to give the client fluids, and thicken them if needed to make them easier to swallow.
Choice C reason: Instructing the client to chew on the left side of their mouth is not a good idea, as the left side is paralyzed and has reduced sensation. The client may not be able to chew or feel the food on that side, and may accidentally bite their tongue or cheek. The nurse should instruct the client to chew on the right side of their mouth, which is unaffected by the stroke.
Choice D reason: Instructing the client to swallow with their head tilted back is not a good practice, as it can open the airway and allow food or liquid to enter the lungs. The nurse should instruct the client to swallow with their head tilted slightly forward, which can close the airway and direct the food or liquid to the esophagus.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B reason: Lentils are a rich source of folate, which is a B vitamin that is essential for the development of the neural tube and the prevention of neural tube defects in the fetus . One cup of cooked lentils provides about 358 micrograms of folate, which is 90% of the recommended daily intake for pregnant women.
Choice A reason: Mashed potatoes are not a good source of folate, as they contain only 8 micrograms of folate per cup, which is 2% of the recommended daily intake for pregnant women. Potatoes are mainly a source of carbohydrates, potassium, and vitamin C.
Choice C reason: Green peppers are a moderate source of folate, as they contain 42 micrograms of folate per cup, which is 11% of the recommended daily intake for pregnant women. Green peppers are also a source of vitamin C, vitamin A, and fiber.
Choice D reason: Carrots are a low source of folate, as they contain 24 micrograms of folate per cup, which is 6% of the recommended daily intake for pregnant women. Carrots are mainly a source of vitamin A, beta-carotene, and fiber.
Correct Answer is D
Explanation
Choice A reason: Green tea is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Green tea contains tannins, which are compounds that bind to iron and prevent its absorption. The nurse should advise the client to avoid drinking green tea or other beverages that contain tannins, such as black tea, with meals that contain iron.
Choice B reason: Coffee is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Coffee also contains tannins, as well as caffeine, which can interfere with iron absorption. The nurse should recommend the client to limit or avoid coffee intake, especially with iron-rich foods.
Choice C reason: Milk is not a beverage that enhances the absorption of nonheme iron, but rather inhibits it. Milk contains calcium, which can compete with iron for absorption. The nurse should suggest the client to consume milk and other dairy products separately from iron-containing foods.
Choice D reason: Orange juice is a beverage that enhances the absorption of nonheme iron, as it is rich in vitamin C. Vitamin C can increase the absorption of nonheme iron by converting it from the ferric form to the more absorbable ferrous form. The nurse should encourage the client to drink orange juice or other citrus juices with meals that contain iron.
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