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. "Eating yogurt can help decrease gas odor that I have."
This is the correct choice. Yogurt contains probiotics, which can contribute to a healthy balance of bacteria in the digestive system, potentially reducing gas odor associated with a colostomy.
B. "I should eliminate pasta from my diet so that I don’t have as many loose stools."
This statement is incorrect. Pasta, as a general rule, is not associated with causing loose stools. Dietary adjustments should be individualized, and specific triggers for loose stools vary among individuals.
C. "My largest meal of the day should be in the evening."
While meal timing can vary based on personal preferences and lifestyle, there is no strict rule that the largest meal must be in the evening. It depends on individual habits and dietary needs.
D. "Carbonated beverages can help control odor."
This statement is incorrect. Carbonated beverages are not typically associated with controlling odor related to a colostomy. In fact, they may contribute to increased gas production, potentially exacerbating odor issues.
Correct Answer is D
Explanation
Correct answer: D
A. "Use mineral oil to relieve constipation.": Mineral oil is not recommended during pregnancy because it can interfere with the absorption of fat-soluble vitamins (A, D, E, K).
B. "Drink 1 liter of water daily to decrease constipation.": While hydration is important, 1 liter of water is insufficient. Pregnant clients are advised to drink more, typically around 2-3 liters daily, to help with digestion and prevent constipation.
C. "Use an enema when constipation occurs.": Enemas are generally not recommended during pregnancy without consulting a healthcare provider, as they may stimulate uterine contractions.
D. “Eat an apple to help with constipation.”Apples are high in fiber, which helps to promote bowel regularity and prevent constipation, making them a healthy option for managing constipation during pregnancy.
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