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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Warfarin is an anticoagulant used to prevent blood clots. While it may be prescribed for certain patients at risk for stroke, it is not typically the first-line medication for managing TIA or hyperlipidemia. It is more often used in patients with specific types of atrial fibrillation or mechanical heart valves.
B. Simethicone is an anti-foaming agent used to relieve gas and bloating. It does not have any role in managing hyperlipidemia or preventing strokes. Thus, this option is not relevant to the client's condition.
C. Simvastatin is a statin medication used to lower cholesterol levels and reduce the risk of cardiovascular events, including stroke. For a client with hyperlipidemia and a history of TIA, simvastatin would be an appropriate medication to help manage cholesterol and decrease the risk of future ischemic events.
D. Enoxaparin is a low-molecular-weight heparin used for anticoagulation, often in the context of deep vein thrombosis or pulmonary embolism. It may not be the first choice for TIA management. While it has its uses in preventing clot formation, it is not the standard treatment for a patient who has had a TIA.
Correct Answer is B
Explanation
A. Clopidogrel is not a pain medication; it is an antiplatelet agent used to reduce the risk of stroke and other cardiovascular events. It should be taken regularly, not on an as-needed basis.
B. Clopidogrel works by inhibiting platelet aggregation, which helps prevent the formation of blood clots that can lead to strokes. This understanding indicates that the client recognizes the purpose of the medication and its importance in managing their condition after a TIA.
C. Clopidogrel is not used to treat anxiety; it is primarily focused on reducing the risk of thrombotic events. This choice shows a misunderstanding of the medication's purpose.
D. Clopidogrel does not directly control blood pressure; it is used to prevent blood clots. While blood pressure management is essential in the context of stroke prevention, clopidogrel itself does not have a role in lowering blood pressure.
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