The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Assisting the client with meals

Placing food on the affected side of the mouth

Testing the gag reflex before offering food or fluids

Allowing ample time to eat

Answer and Explanation

The Correct Answer is B

A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.

B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.

C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.

D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.

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Correct Answer is B

Explanation

A. "Her family will no longer be dysfunctional." Completing a treatment program does not guarantee that family dynamics will change or improve immediately. Family dysfunction is often deeply rooted and requires separate or concurrent therapy.

B. "She'll need ongoing support to remain abstinent." Recovery from alcoholism is an ongoing process, and continued support, whether through therapy, support groups, or counseling, is critical to maintaining abstinence and preventing relapse.

C. "She doesn't need to be concerned about abusing alcohol in the future." This statement is inaccurate because individuals recovering from alcoholism must remain vigilant to prevent relapse. Alcoholism is a chronic condition, and the risk of relapse remains.

D. "She can learn to consume alcohol without problems." This is incorrect, as individuals who have struggled with alcoholism typically need to abstain completely from alcohol to prevent relapse.

A. Report the finding so a sleep medication can be prescribed. B. Clarify what the client means by trouble falling asleep. C. Ask the client what they do before going to bed. D. Question the client about their use of caffeine.

Correct Answer is B

Explanation

A. Report the finding so a sleep medication can be prescribed. While this might eventually be necessary, it's premature to suggest medication without further assessing the problem. Other interventions could be tried first.

B. Clarify what the client means by trouble falling asleep. Clarifying the client's statement is essential to understand the specific nature of the sleep problem, such as how long it takes to fall asleep, how often it occurs, and whether there are any contributing factors. This is a critical step in assessment before any further action.

C. Ask the client what they do before going to bed. This is a good follow-up question, but it should come after clarification of what the client means by trouble falling asleep. Understanding pre-bedtime routines is important but secondary to defining the issue.

D. Question the client about their use of caffeine. While this is a relevant question that could affect sleep patterns, it should follow after understanding the client's specific sleep issues.

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The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

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