Exhibits
A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements
"I will look up at the ceiling when I swallow."
"I will have to stop watching television while I eat."
"My food will have to be the consistency of pudding."
"I can have cream soups on this diet."
"I shouldn't drink liquids while I have food in my mouth."
"I won't be able to eat nuts anymore."
Correct Answer : B,C,E,F
A. "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B. "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C. "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D. "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E. "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F. "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this is a good safety measure for any client, it doesn't address the specific issue of homonymous hemianopsia.
B. This can be helpful for clients with motor difficulties but does not address the visual impairment.
C. Since the client has a right-sided stroke and homonymous hemianopsia, they will likely miss food on the left side of their tray. Reminding them to scan that area can help prevent them from missing food.
D. While this might seem logical, it doesn't address the underlying issue of the client's visual impairment.
Correct Answer is D
Explanation
The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.
Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.
The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.
Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.
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