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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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.

A. Massage the client’s bony prominences. B. Keep the head of the bed elevated. C. Reposition the client at least every 2 hr. D. Keep the client’s skin moist.

Correct Answer is C

Explanation

A. Massage the client’s bony prominences:

Massaging bony prominences is generally not recommended for individuals at risk for pressure ulcers. Massage can increase friction and shear forces on the skin, which may contribute to skin damage rather than prevent it. Gentle, careful handling of the skin is preferable.

B. Keep the head of the bed elevated:

While elevating the head of the bed may be appropriate for certain medical conditions, it is not a primary preventive measure for pressure ulcers. In fact, keeping the head of the bed elevated continuously can contribute to pressure on the sacrum and coccyx, increasing the risk of pressure ulcers in those areas.

C. Reposition the client at least every 2 hr:

Regular repositioning is a crucial preventive measure for pressure ulcers. Repositioning helps redistribute pressure, improves blood flow to vulnerable areas, and reduces the risk of skin breakdown.

D. Keep the client’s skin moist:

While maintaining skin moisture is important to prevent dryness and cracking, excessive moisture can contribute to skin breakdown. The emphasis should be on keeping the skin clean and dry, with the use of moisturizers applied judiciously to prevent excessive dryness.

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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 B

Explanation

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Correct Answer is C

Explanation

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