A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

Instruct the client to tilt her head back when she swallows.

Place food on the left side of the client’s mouth.

Add thickener to fluids.

Serve food at room temperature.

Answer and Explanation

The Correct Answer is C

A. Instruct the client to tilt her head back when she swallows.

Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.

B. Place food on the left side of the client’s mouth.

Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.

C. Add thickener to fluids.

This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.

D. Serve food at room temperature.

While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Check that the client lifts the walker and then places it down in front of her.

To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.

B. Walk in front of the client to guide her in moving the walker.

The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.

C. Have the client move one leg forward with the walker.

The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.

D. Make sure that the upper bar of the walker is level with the client’s waist.

The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.

A. “I don’t take naps throughout the day.” B. “I go to bed and get up at the same times each day.” C. “I have a small snack and take a bath before going to bed each day.” D. “I watch television until I fall asleep at night.”

Correct Answer is D

Explanation

A. “I don’t take naps throughout the day.”

This statement suggests that the client avoids daytime napping, which is generally a positive sleep habit. Excessive daytime napping can interfere with nighttime sleep.

B. “I go to bed and get up at the same times each day.”

Maintaining a consistent sleep schedule is a key component of good sleep hygiene. Going to bed and waking up at the same times helps regulate the body's internal clock.

C. “I have a small snack and take a bath before going to bed each day.”

Having a light snack and engaging in a relaxing activity like a bath before bedtime can contribute to a more conducive sleep environment. However, the type and timing of the snack should be considered.

D. “I watch television until I fall asleep at night.”

This statement may indicate a need for further instruction. Watching television right before bedtime, especially until falling asleep, can be counterproductive to good sleep hygiene due to the stimulating effects of the screen's blue light.

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A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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