A 77-year-old female client experienced a stroke several weeks ago that has left her with several motor and sensory deficits, including dysphagia. The client is receiving a diet with a modified texture that is easier to chew and swallow. What nursing action should the nurse perform in order to maintain this client's safety during feeding?

Ensure that there is a complete and functional suction system at the bedside.

Position the head of the client's bed at a height of 30° to 45°.

Provide two larger meals each day rather than three smaller meals in order to prevent fatigue.

Encourage the client to hold her breath while she is attempting to swallow.

Answer and Explanation

The Correct Answer is A

A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.

B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.

C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.

D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.

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Correct Answer is B

Explanation

A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.

B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.

C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.

D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.

A. "I am not on vacation. I am here with you." B. "How can I go on vacation. I do not have any money." C. "Stop saying that. You know better. No one told you that." D. "Just forget about that and let's talk about something else."

Correct Answer is A

Explanation

A. "I am not on vacation. I am here with you." This response calmly reassures the client by affirming the mother’s presence, which helps address the son’s confusion without directly challenging his perception.

B. "How can I go on vacation? I do not have any money." This response could increase confusion and does not address the son's needs effectively. It could also lead to unnecessary discussions that might not be helpful.

C. "Stop saying that. You know better. No one told you that." This response is dismissive and confrontational, which may exacerbate the son’s distress and could damage the therapeutic relationship.

D. "Just forget about that and let's talk about something else." This response avoids addressing the son’s concerns, which can make him feel dismissed and not listened to, potentially worsening his symptoms.

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Naxlex Comprehensive Predictor Exams

The nurse is interviewing a client with major depression. Which of the following statements by the client would most indicate to the nurse that the client is at risk for suicide?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A client with depression is admitted to an inpatient psychiatric unit. The nurse provides a unit orientation. While observing the client's unpacking, the nurse can expect the client to exhibit:

Which type of therapy assists the clients to alter their irrational thinking?

A nurse is caring for a client with complaints of xerostomia. The nurse should encourage the client to:

A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

A client is admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive symptoms. Obsessive- compulsive disorder (OCD) is associated with:

The nurse is providing education via phone to a client who called stating that the newly prescribed imipramine (Tofranil) is not working as depression is still a problem. Which question is most important to ask first?

The nurse is caring for a client who has has been inhaling solvents to receive a "high." After the nurse provides education on the effects of inhaling solvents, which statement from the client indicates understanding of the teaching?

A nurse is preparing to administer prednisone to a client for treatment of rheumatoid arthritis. Which of the following findings indicates to the nurse the treatment is effective?