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 C
Explanation
Choice A reason: "Use simple, childlike statements when speaking." This response is not appropriate because it can be demeaning and disrespectful to the client. The client is an adult who knows what they want to say, but they have difficulty saying it. Using simple statements is helpful, but they should not be childlike or patronizing.
Choice B reason: "Use a higher pitched tone of voice when speaking." This response is not appropriate because it can be irritating and confusing to the client. The client may have normal hearing, or they may have hearing loss due to age or stroke. Using a higher pitched tone of voice can make the speech harder to understand and may imply that the client is not intelligent.
Choice C reason: "Incorporate nonverbal cues in the conversation." This response is appropriate because nonverbal cues, such as gestures, facial expressions, and drawings, can help the client understand and express themselves better. Nonverbal cues can also reduce frustration and anxiety for both the client and the family member.
Choice D reason: "Ask multiple choice questions as part of the conversation." This response is not appropriate because it can be overwhelming and stressful for the client. Multiple choice questions can be hard to process and remember for someone with aphasia. It is better to ask yes or no questions, or to provide options with visual cues.
Correct Answer is A
Explanation
Choice A reason: A stroke involving the right cerebral hemisphere can affect the cognitive and emotional functions of the brain, such as judgment, impulse control, and emotional regulation³. This can lead to risky or inappropriate behaviors, such as acting impulsively or disregarding social norms. Therefore, the nurse should monitor the client for poor impulse control and provide appropriate interventions, such as education, cueing, feedback, and environmental modifications.
Choice B reason: A stroke involving the right cerebral hemisphere can affect the visual functions of the brain, such as depth perception, spatial orientation, and visual recognition³. However, the deficits are usually in the left visual field, not the right, because the right side of the brain controls the left side of the body and the environment. Therefore, the nurse should monitor the client for deficits in the left visual field, not the right.
Choice C reason: A stroke involving the right cerebral hemisphere can affect the abstract reasoning functions of the brain, such as understanding metaphors, humor, or sarcasm. However, the ability to discriminate words and letters is more related to the language functions of the brain, which are mainly controlled by the left cerebral hemisphere. Therefore, the nurse should monitor the client for language deficits, such as aphasia or dysarthria, if the stroke involves the left cerebral hemisphere, not the right.
Choice D reason: A stroke involving the right cerebral hemisphere can affect the motor functions of the brain, such as movement, coordination, and balance³. However, the motor retardation, which is a slowing down of physical and mental activity, is more related to the mood functions of the brain, which are mainly controlled by the frontal lobe of the brain. Therefore, the nurse should monitor the client for motor retardation if the stroke involves the frontal lobe, not the right cerebral hemisphere.
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