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 C

Explanation

A. “You should avoid the use of cell phones after the pacemaker is placed.”

This statement is not accurate. In general, the use of cell phones is considered safe for individuals with pacemakers. However, it is recommended to keep the phone on the opposite side of the pacemaker to minimize any potential interference.

B. “Swelling and redness of the operative site are normal findings for the first two days following the

procedure.”

This statement is partially accurate. Swelling and redness at the operative site can be expected immediately after the procedure. However, if these signs persist or worsen after the first two days, it may indicate a potential issue, and the healthcare provider should be notified.

C. “You will need to limit movement of the arm on the side of the pacemaker.”

This statement is accurate. Limiting movement of the arm on the side of the pacemaker is a standard precaution to prevent dislodgement of the leads and allow proper embedding of the pacemaker leads into the surrounding tissues.

D. “Hiccups following pacemaker placement are an expected response.”

This statement is not accurate. Hiccups are not typically associated with pacemaker placement. If the client experiences unexpected symptoms, such as hiccups, it is important to report them to the healthcare provider for further evaluation.

A. I will rest for at least 30 minutes before eating. B. I will drink plenty of beverages with my meals. C. I will eat five or six small meals each day? D. I will increase my intake of protein.

Correct Answer is B

Explanation

A. "I will rest for at least 30 minutes before eating."
This statement is appropriate. Resting before meals can help conserve energy and reduce dyspnea (shortness of breath) during eating for individuals with COPD.

B. "I will drink plenty of beverages with my meals."
This statement indicates a need for further teaching. Excessive fluid intake during meals can contribute to feelings of fullness and increase the risk of bloating, making it more difficult for the client with COPD to breathe comfortably.

C. "I will eat five or six small meals each day."
This statement is appropriate. Eating smaller, more frequent meals can help prevent overdistension of the stomach and reduce the feeling of fullness, making it easier for the client to breathe.

D. "I will increase my intake of protein."
This statement is appropriate. Adequate protein intake is important for individuals with COPD to support respiratory muscle function and overall nutritional status.

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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

A nurse is reinforcing teaching with a client who is scheduled to have a permanent pacemaker implanted. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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