The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?
Delegate the feeding to the nursing student.
Place the food on the affected side of the mouth.
Keep the television off while feeding the client.
Ensure the client's head of the bed is less than 30 degrees.
The Correct Answer is C
A. While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B. Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C. Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D. The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While it's important to monitor the surgical dressing, changing it too frequently can increase the risk of infection and disrupt healing. Instead, nurses typically assess the dressing regularly and only change it if it's overly saturated or if ordered by a physician. It’s essential to follow specific protocols regarding dressing changes.
B. A While breast prostheses can be an important part of post-mastectomy care for some clients, it is usually recommended that clients wait until they have fully healed and received counseling regarding their options. Immediate encouragement may be premature, as physical and emotional adjustments take time after surgery.
C. This is an appropriate intervention. After axillary lymph node dissection, there is a risk of lymphedema in the affected arm. Placing a limb alert bracelet serves as a reminder to healthcare providers to avoid taking blood pressure or performing venipunctures on the affected arm, thus helping prevent complications.
D. While PCA can be an effective method for managing postoperative pain, the timing and dosage should be based on the specific prescription and the client's individual needs. It’s crucial to educate the client about the PCA device and its use, but the specific interval may vary based on the medication's parameters and the patient's condition.
Correct Answer is A
Explanation
A. A mass in the mediastinum can compress the trachea or major blood vessels, leading to shortness of breath, particularly when the patient is in a supine position (lying flat). This symptom is indicative of significant obstruction or compression, making it a key sign.
B. While lymphadenopathy (swelling of lymph nodes) is a hallmark of Hodgkin's Lymphoma, it does not specifically indicate the presence of a mediastinal mass. Lymph nodes can swell throughout the body, including cervical, axillary, and inguinal regions, but this symptom is more general and not exclusive to mediastinal involvement.
C. Low-grade fevers can occur in Hodgkin's Lymphoma due to systemic effects of the cancer, such as cytokine release. However, this symptom is nonspecific and does not directly indicate a mediastinal mass. It is more indicative of the body's response to cancer rather than localized effects.
D. Drenching night sweats are another common systemic symptom associated with Hodgkin's Lymphoma. Like low-grade fevers, night sweats are part of the B symptoms that can occur with lymphoma but are not specifically indicative of a mediastinal mass.
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