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.
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Related Questions
Correct Answer is C
Explanation
A. Skeletal traction
Skeletal traction involves the use of pins or wires that are surgically inserted directly into the bone. It is a more invasive form of traction commonly used during or after surgery. Skeletal traction provides a strong and direct pull on the bones, allowing for better alignment and immobilization.
B. Pelvic sling
A pelvic sling is not a specific type of traction. It may refer to a supportive device or garment that helps stabilize the pelvis. While it can provide support, it does not apply the same type of traction force as Buck's traction or skeletal traction.
C. Buck’s traction
Buck's traction is a type of skin traction commonly used as a temporary measure to immobilize and align fractured bones, particularly in the lower extremities. It involves the application of a boot or a splint to the affected leg, with traction applied through a system of weights and pulleys. Buck's traction is often used before hip surgery.
D. Russell’s traction
Russell's traction involves the application of traction to the lower leg using a splint and bandages. It is often used for fractures of the femur. While it is a form of traction, it is not commonly used for hip fractures.
Correct Answer is B
Explanation
A. Ensure the rope knots are away from the pulleys.
While ensuring that rope knots are away from the pulleys is a general principle in traction care to maintain proper functioning, it is not directly related to the specific positioning of the child's feet in Buck's traction.
B. Ensure the child’s feet are against the footboard.
This statement is correct. Ensuring that the child's feet are against the footboard helps maintain proper hip alignment and prevent complications such as contractures. It is an important aspect of care when managing Legg-Calve-Perthes disease in Buck's traction.
C. Apply antibiotic ointment to the pin sites daily.
This action is not applicable to Buck's traction. Buck's traction involves the use of a boot or splint, and it does not include pins or pin sites. The use of antibiotic ointment for pin sites is more relevant in the context of skeletal traction.
D. Reduce the child’s fluid intake.
There is no indication to reduce the child's fluid intake specifically in the context of Buck's traction. Adequate hydration is generally important for overall health, and fluid restriction is not a standard practice for managing Legg-Calve-Perthes disease in Buck's traction.
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