A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should the nurse recommend?
Apple juice
Oatmeal
Broth
Toast
The Correct Answer is B
A. Apple juice: Thin liquids like apple juice can be difficult for clients with dysphagia to control, increasing the risk of aspiration. These should generally be thickened or avoided based on the client’s swallowing ability.
B. Oatmeal: Soft, pureed, or thick foods like oatmeal are easier to swallow and reduce the risk of aspiration. Oatmeal has a cohesive texture that allows safer swallowing for clients with dysphagia.
C. Broth: Clear liquids such as broth are thin and can easily enter the airway, increasing the risk of choking or aspiration in clients with swallowing difficulties.
D. Toast: Dry, hard foods like toast can be difficult to chew and form into a cohesive bolus, making swallowing unsafe for clients with dysphagia.
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Related Questions
Correct Answer is C
Explanation
A. Assist the client to a supine position: There is no requirement to maintain a supine position for bacterial meningitis. Clients are often more comfortable with the head of the bed elevated to reduce intracranial pressure and promote comfort. Supine positioning alone does not prevent disease transmission or improve outcomes.
B. Recommend prophylactic acyclovir for the client's family: Acyclovir is an antiviral medication and is not effective against bacterial infections. Family members may require prophylactic antibiotics if exposed, but antiviral therapy is inappropriate for bacterial meningitis.
C. Initiate droplet precautions for the client: Bacterial meningitis, particularly Neisseria meningitidis, can be transmitted via respiratory droplets. Implementing droplet precautions, including the use of masks and limiting close contact, protects healthcare staff and other clients from infection. This is a standard and critical infection control measure.
D. Perform a Glasgow Coma Scale every 24 hr: Clients with bacterial meningitis are at risk for rapid neurological changes. Performing a Glasgow Coma Scale only once every 24 hours is insufficient. Neurological status should be monitored more frequently to promptly identify deterioration.
Correct Answer is B
Explanation
A. Schedule routine oral suctioning: Suctioning can increase intracranial pressure and should be performed only when necessary, using short, gentle passes. Routine suctioning is not recommended for a child with increased ICP, as it can exacerbate neurological injury.
B. Pad the side rails of the bed: An unresponsive child is at high risk for injury from involuntary movements or seizures. Padding the side rails helps prevent trauma and is a key safety intervention in children with increased intracranial pressure, making it the priority action in this scenario.
C. Obtain isolation supplies: Isolation precautions are only needed if the child has a contagious condition. Increased intracranial pressure does not automatically indicate a risk of infection transmission, so isolation supplies are not immediately necessary.
D. Place the child in Trendelenburg position: Trendelenburg positioning (head-down) can further increase intracranial pressure and is contraindicated. Children with elevated ICP should be positioned with the head of the bed elevated to promote venous drainage and reduce pressure.
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