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 ["A","B","C","D"]

Explanation

A. Monitoring the client for neuroleptic malignant syndrome for up to 2 months after initiating the drug. Neuroleptic malignant syndrome (NMS) is a rare but serious adverse effect of antipsychotic medications. Monitoring for NMS, especially during the first few months of treatment, is crucial.

B. Encouraging the client to report signs of diabetes, such as increased thirst, hunger, and urination. Some antipsychotics, particularly second-generation antipsychotics, are associated with an increased risk of metabolic syndrome, including diabetes. Clients should be educated to report symptoms suggestive of hyperglycemia.

C. Advising the client to report weight gain and skin rashes to the health care provider immediately. Weight gain is a common side effect, particularly with second-generation antipsychotics. Skin rashes could indicate an allergic reaction, including serious conditions like Stevens-Johnson syndrome, requiring immediate medical attention.

D. Using the Abnormal Involuntary Movement Scale (AIMS) to assess for neurologic adverse effects. The AIMS scale is used to assess for tardive dyskinesia and other extrapyramidal symptoms, which are potential adverse effects of antipsychotic medications.

E. Administering the medication subcutaneously when the client is unable to swallow effectively. Antipsychotic medications are generally not administered subcutaneously. If a client cannot swallow, an alternative route such as intramuscular injection or an orally disintegrating tablet might be used.

A. emaciation B. cachexia C. anorexia D. nausea

Correct Answer is C

Explanation

A. Emaciation: Emaciation refers to extreme weight loss and muscle wasting due to severe malnutrition, not just loss of appetite.

B. Cachexia: Cachexia is a complex syndrome associated with chronic illness, characterized by severe weight loss, muscle atrophy, and fatigue. While it may include loss of appetite, it’s not the best term for simple loss of appetite.

C. Anorexia: Anorexia is the correct medical term for loss of appetite. It can be related to various conditions, including prolonged illness.

D. Nausea: Nausea is a sensation of discomfort in the stomach with an urge to vomit, not loss of appetite.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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