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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Offer to request a prescription for an indwelling urinary catheter.
Indwelling urinary catheters carry risks, including the risk of infection, and should not be used solely for the purpose of addressing the fear of falling. Catheter use should be based on medical necessity.
B. Keep a night light on in the client’s room.
This is the most appropriate action. Keeping a night light on can help the client navigate the new surroundings more safely and reduce the risk of falls due to disorientation.
C. Limit the client’s fluid intake in the evening.
Limiting fluid intake, especially in the absence of a medical indication, may lead to dehydration and is not the best solution for addressing the fear of falling.
D. Put the side rails up and tell the client to call for assistance to the bathroom.
While encouraging the client to call for assistance is important, putting all four side rails up can be considered a restraint. Restraints should be avoided whenever possible to promote mobility and independence. It's important to balance safety with maintaining the client's autonomy.
Correct Answer is C
Explanation
A. Stomatitis
Stomatitis refers to inflammation of the oral mucosa, which includes the lips, cheeks, gums, tongue, and palate. It can be caused by various factors, such as infections, irritants, or systemic conditions. While stomatitis may contribute to changes in oral odor, it encompasses a broader range of inflammatory conditions within the oral cavity.
B. Gingivitis
Gingivitis is inflammation of the gums (gingiva). It is often caused by plaque buildup and can lead to redness, swelling, and bleeding of the gums. While gingivitis may contribute to bad breath, it specifically involves inflammation of the gum tissue.
C. Halitosis
Halitosis refers to bad breath or a strong mouth odor. It can be caused by various factors, including poor oral hygiene, infections, dental conditions, or systemic diseases. In the context of a client with facial fractures, the nurse might observe halitosis due to challenges in maintaining oral hygiene or potential injuries.
D. Pyorrhea
Pyorrhea is an outdated term that was historically used to describe advanced stages of periodontal disease, including inflammation of the gums and supporting structures. The term is not commonly used in modern dental or medical terminology.
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