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 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.
Correct Answer is C
Explanation
A. "Skeletal traction has less risk for infection than skin traction."
This statement is not accurate. Both skeletal and skin traction carry some risk of infection, but the risk factors and considerations are different for each. Skeletal traction involves pins or wires directly inserted into the bone, and while the risk of infection is present, it is not necessarily lower than that of skin traction.
B. "Clients in skin traction have more mobility than those in skeletal traction."
This statement is not accurate. Skeletal traction, involving the use of weights and pins or wires inserted into the bone, tends to provide more stable immobilization. Skin traction, which relies on external devices applied to the skin's surface, may allow for some limited mobility but is generally not as effective as skeletal traction.
C. "Skeletal traction is better than skin traction for reducing a fracture."
This is the correct statement. Skeletal traction is often more effective in providing a stable and controlled environment for reducing and immobilizing fractures.
D. "Clients in skin traction have more discomfort than those in skeletal traction."
This statement is not necessarily accurate. Discomfort can vary depending on the individual, the type of fracture, and other factors. Both skeletal and skin traction may cause some discomfort, and it's important to assess and manage the client's pain appropriately in either case.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
