A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client’s partner should indicate to the nurse that the teaching was effective?
My partner should place their food on the weaker side of their mouth when eating.
My partner should tilt their head forward when swallowing.
My partner should cough while swallowing food.
My partner should sit at a 30° angle while eating their meals.
The Correct Answer is B
Choice A reason: Placing food on the weaker side of the mouth when eating is not an effective strategy for a client who has dysphagia. This can increase the risk of choking or aspiration, as the food may not be chewed properly or may slip into the airway. The client should place food on the stronger side of the mouth and use the tongue to move it to the back of the throat for swallowing.
Choice B reason: Tilting the head forward when swallowing is an effective technique for a client who has dysphagia. This can help to close off the airway and prevent food or liquid from entering the lungs. The client should also tuck the chin down to the chest and swallow hard.
Choice C reason: Coughing while swallowing food is not a desirable outcome for a client who has dysphagia. This can indicate that the food is going into the wrong pipe and causing irritation or obstruction. The client should try to avoid coughing while swallowing and clear the throat after each bite or sip.
Choice D reason: Sitting at a 30° angle while eating meals is not a sufficient position for a client who has dysphagia. This can still allow food or liquid to flow back into the throat and cause choking or aspiration. The client should sit upright at a 90° angle and remain in that position for at least 30 minutes after eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A history of neurologic deficits lasting less than 1 hr is not a typical manifestation of a hemorrhagic stroke. This could be a sign of a transient ischemic attack (TIA), which is a temporary blockage of blood flow to the brain that causes stroke like symptoms. A TIA is different from a hemorrhagic stroke, which is caused by bleeding in the brain due to a ruptured blood vessel.
Choice B reason: Manifestations preceded by a severe headache is a common manifestation of a hemorrhagic stroke. A ruptured cerebral aneurysm can cause sudden and intense pain in the head, often described as the worst headache of one's life. This is due to the increased pressure and irritation of the brain tissue and nerves by the blood leaking from the aneurysm.
Choice C reason: A gradual onset of several hours is not a usual manifestation of a hemorrhagic stroke. A hemorrhagic stroke is a medical emergency that requires immediate treatment, as the bleeding can cause rapid damage to the brain and increase the risk of death or disability. The symptoms of a hemorrhagic stroke usually develop suddenly and worsen quickly.
Choice D reason: Maintaining consciousness is not a likely manifestation of a hemorrhagic stroke. A hemorrhagic stroke can cause loss of consciousness, confusion, drowsiness, or coma due to the reduced blood flow and oxygen to the brain. The level of consciousness can also be affected by the location and extent of the bleeding, as well as the presence of complications such as hydrocephalus or vasospasm.
Correct Answer is A
Explanation
Choice A reason: The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygen saturation of the arterial blood. Central cyanosis occurs when the arterial blood has a low oxygen saturation due to a cardiopulmonary problem. The oral mucosa is less affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation.
Choice B reason: The conjunctivae are not a reliable indicator of central cyanosis because they can be affected by other conditions such as anemia, jaundice, or eye infections. The conjunctivae are the thin membranes that cover the white part of the eye and the inner surface of the eyelids.
Choice C reason: The ear lobes are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The ear lobes are the fleshy lower part of the external ear.
Choice D reason: The soles of the feet are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The soles of the feet are the bottom part of the feet.
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