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 A
Explanation
Choice A reason: Confusion and weakness are signs of dehydration and electrolyte imbalance, which can result from vomiting and diarrhea. These are serious complications that can affect the client's mental status, blood pressure, heart rate, and kidney function. The nurse should report these changes to the provider and monitor the client's vital signs and fluid status.
Choice B reason: Dry oral mucosa and furrowed tongue are also signs of dehydration, but they are less severe than confusion and weakness. The nurse should report these changes to the provider as well, but they are not the most urgent ones.
Choice C reason: Clear lungs bilaterally are a normal finding and do not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Choice D reason: A soft and non-tender abdomen is a normal finding and does not indicate any change in the client's condition. The nurse should document this finding, but it does not require reporting to the provider.
Correct Answer is C
Explanation
Choice A reason:A firm bilateral hand grip indicates normal muscle strength, which is a positive sign but not directly related to hypernatremia treatment efficacy.
Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.
Choice C reason:Deep tendon reflexes graded as 2+ are considered normal and suggest that neuromuscular function is intact. Since hypernatremia can cause neuromuscular excitability, normal reflexes may indicate effective treatment.
Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.
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