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.
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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Related Questions
Correct Answer is B
Explanation
A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
Correct Answer is A
Explanation
A. Body temperature control: The hypothalamus regulates body temperature. Damage to this area can lead to difficulties with maintaining normal body temperature.
B. Balance and equilibrium: Balance and equilibrium are primarily managed by the cerebellum and vestibular system, not the hypothalamus.
C. Visual acuity: Visual acuity is regulated by the occipital lobe of the brain, not the hypothalamus.
D. Thinking and
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