A male client was admitted with a left-sided stroke this morning. The assistive personnel asks about meeting the client’s nutritional needs. Which response by the nurse is appropriate?
He is NPO until the speech-language pathologist performs a swallowing evaluation.
Be sure to sit him up when you are feeding him to make him feel more natural.
You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.
Just be sure to add some thickener in his liquids to prevent choking and aspiration.
None
None
The Correct Answer is A
Choice A: He is NPO until the speech-language pathologist performs a swallowing evaluation.
When a client is admitted with a stroke, especially one affecting the left side, there is a significant risk of dysphagia, or difficulty swallowing. This can lead to choking and aspiration, which can cause pneumonia and other complications. Therefore, it is crucial to keep the client NPO (nothing by mouth) until a speech-language pathologist can perform a thorough swallowing evaluation. This ensures that the client can safely swallow without the risk of aspiration. The speech-language pathologist will assess the client’s ability to swallow different textures and consistencies of food and liquids and provide recommendations for safe feeding.
Choice B: Be sure to sit him up when you are feeding him to make him feel more natural.
While sitting the client up during feeding is a good practice to reduce the risk of aspiration, it is not sufficient on its own for a client who has just had a stroke. Without a proper swallowing evaluation, feeding the client could still pose a significant risk. Therefore, this choice is not the most appropriate response.
Choice C: You may give him a full-liquid diet, but please avoid solid foods until he gets stronger.
A full-liquid diet might seem like a safer option, but it still poses a risk of aspiration if the client has dysphagia. Without a swallowing evaluation, it is not safe to assume that the client can handle even a full-liquid diet. Therefore, this choice is not appropriate.
Choice D: Just be sure to add some thickener in his liquids to prevent choking and aspiration.
Adding thickener to liquids can help some clients with dysphagia, but it is not a one-size-fits-all solution. The appropriate consistency of liquids should be determined by a speech-language pathologist after a swallowing evaluation. Therefore, this choice is not appropriate without a prior assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Order a high-fiber diet
Choice A Reason:
Encourage dietary intake
Encouraging dietary intake is generally important for maintaining nutritional status, but it is not specific to the preparation for a barium enema. The preparation for a barium enema typically involves dietary restrictions to ensure the colon is clear for the procedure. Therefore, this choice is not correct.
Choice B Reason:
Encourage plenty of fat
Encouraging plenty of fat is not appropriate for the preparation of a barium enema. High-fat foods can slow down the digestive process and may interfere with the clarity of the images obtained during the procedure. Therefore, this choice is not correct.
Choice C Reason:
Serve dairy products
Serving dairy products is not recommended before a barium enema. Dairy products can cause gas and bloating, which can interfere with the procedure. Additionally, some patients may be lactose intolerant, which can further complicate the preparation. Therefore, this choice is not correct.
Choice D Reason:
Order a high-fiber diet
Ordering a high-fiber diet is the correct choice. A high-fiber diet helps to clear the intestines by promoting bowel movements. This is important for ensuring that the colon is empty and clear for the barium enema, which allows for better imaging and more accurate results.
Correct Answer is D
Explanation
Choice A reason: No change to the heparin rate is not appropriate in this scenario. The normal range for PTT is generally between 25 to 35 seconds. However, for a client on heparin therapy, the target PTT is typically 1.5 to 2.5 times the normal range, which would be approximately 60 to 80 seconds. Since the client’s PTT is only 25 seconds, it indicates that the blood is clotting too quickly, and the heparin dose is insufficient.
Choice B reason: Decreasing the heparin rate would further reduce the anticoagulant effect, which is not advisable given the current PTT of 25 seconds. Lowering the heparin rate could increase the risk of thrombus formation and worsen the deep vein thrombosis (DVT) condition.
Choice C reason: Stopping heparin and starting warfarin is not an immediate solution. Warfarin takes several days to achieve its full anticoagulant effect, and during this transition period, the client would be at risk of clot formation. Heparin provides immediate anticoagulation, which is crucial in the acute management of DVT.
Choice D reason: Increasing the heparin rate is the correct action. The current PTT of 25 seconds is below the therapeutic range for a client on heparin therapy. Increasing the heparin rate will help achieve the desired anticoagulant effect, prolonging the PTT to the target range of 60 to 80 seconds.
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