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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B reason: Older adults should decrease their calorie intake as their metabolic rate and physical activity tend to decline with age. Excess calories can lead to weight gain and increase the risk of chronic diseases such as diabetes, cardiovascular disease, and some cancers. Older adults should aim for a balanced diet that meets their nutritional needs without exceeding their energy requirements.
Choice A reason: Older adults should not decrease their vitamin D intake, as vitamin D is essential for bone health and immune function. Older adults are at risk of vitamin D deficiency due to reduced sun exposure, decreased skin synthesis, and impaired absorption. Vitamin D deficiency can cause osteoporosis, fractures, muscle weakness, and infections. Older adults should consume adequate amounts of vitamin D from fortified foods, supplements, or sun exposure.
Choice C reason: Older adults should not decrease their protein intake, as protein is important for maintaining muscle mass, strength, and function. Older adults are prone to sarcopenia, which is the loss of muscle mass and quality due to aging. Sarcopenia can impair mobility, balance, and independence. Older adults should consume enough protein from animal or plant sources to prevent or delay sarcopenia.
Choice D reason: Older adults should not decrease their fiber intake, as fiber is beneficial for digestive health and blood glucose control. Older adults often suffer from constipation, diverticular disease, and diabetes, which can be alleviated by increasing fiber intake. Fiber can also lower cholesterol levels and reduce the risk of heart disease and some cancers. Older adults should consume at least 25 grams of fiber per day from fruits, vegetables, whole grains, legumes, nuts, and seeds.
Correct Answer is B
Explanation
Choice D reason:A metallic taste in the mouth is not a recognized symptom of hyperglycemia. It may occur in other conditions, such as certain medication side effects, infections, or metabolic disorders, but it is not specific to diabetes or high blood glucose levels. Including this as a sign of hyperglycemia could lead to confusion or misinterpretation of symptoms.
Choice A reason: Anxiety is not a specific symptom of hyperglycemia, although it can be associated with stress or other psychological factors that can affect blood sugar levels. Anxiety can also be a symptom of hypoglycemia, or low blood sugar, which requires immediate treatment.
Choice B reason: Hyperventilation, characterized by deep and rapid breathing, is a critical manifestation of severe hyperglycemia, particularly in cases ofdiabetic ketoacidosis (DKA). When blood glucose levels are extremely high, the body may produce ketones, leading to metabolic acidosis. To compensate, the client may developKussmaul respirations, a type of hyperventilation aimed at expelling excess carbon dioxide. This is a medical emergency and requires immediate intervention. Teaching the client to recognize hyperventilation as a sign of severe hyperglycemia is essential for timely treatment and prevention of complications.
Choice C reason: Cool skin is not a symptom of hyperglycemia, but rather a sign of poor circulation, which can be a complication of diabetes. Diabetes can damage the blood vessels and nerves that supply blood and oxygen to the skin, especially in the feet and legs. This can lead to skin problems, infections, and ulcers.
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