A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.
Which of the following instructions should the nurse include?
Encourage brief exercise before meals to promote appetite.
Place the client with the head reclined back to facilitate swallowing.
Encourage the client to take small bites.
Place food in the affected side of the mouth.
The Correct Answer is C
Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.
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