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. “Most of my calories each day should be from fats.”
This statement is not accurate. While fats are essential for a balanced diet, it is not recommended for the majority of calories to come from fats. The emphasis should be on a variety of macronutrients, including carbohydrates and proteins.
B. “I should eat more calories from complex carbohydrates than anything else.”
This is the correct choice. Individuals with diabetes are often encouraged to obtain the majority of their calories from complex carbohydrates. These include whole grains, vegetables, and legumes, which have a slower impact on blood glucose levels.
C. “Simple sugars are needed more than other calorie sources.”
This statement is not accurate for individuals with diabetes. Simple sugars can lead to rapid spikes in blood glucose levels and should be consumed in moderation.
D. “Protein should be my main source of calories.”
This statement is not accurate. While protein is important for overall health, it is not recommended for protein to be the main source of calories. A balanced diet with an emphasis on complex carbohydrates is typically recommended.
Correct Answer is C
Explanation
A. The stockings are used to reduce pain.
This statement is not accurate. While antiembolism stockings may provide some relief from discomfort and swelling, their primary purpose is to prevent venous stasis and reduce the risk of blood clots, not to directly reduce pain.
B. The stockings prevent varicose veins.
This statement is not entirely accurate. While compression stockings can provide some support to veins, their primary role is in preventing blood clots (venous thromboembolism) rather than preventing varicose veins, which are typically related to venous insufficiency.
C. The stockings prevent venous stasis.
This is the correct answer. Antiembolism stockings are specifically designed to prevent venous stasis, which refers to the slowing or stagnation of blood flow in the veins. They exert gentle pressure on the legs to enhance blood circulation and reduce the risk of blood clots.
D. The stockings replace the need for postoperative leg exercises.
This statement is not accurate. While antiembolism stockings are a preventive measure, they do not replace the need for postoperative leg exercises. Leg exercises are important for promoting circulation, preventing complications such as deep vein thrombosis (DVT), and maintaining overall mobility after surgery.
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