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 D
Explanation
A. Elevate the head of the bed: Elevating the head of the bed is not the priority during a seizure. The primary concern is ensuring the client's safety by preventing injury.
B. Restrain the client's arms and legs: Restraining a client during a seizure is not advised, as it can cause injury. Instead, the focus should be on protecting the client from harm.
C. Place a tongue blade in the client's mouth: Placing anything in the client’s mouth during a seizure is contraindicated, as it can lead to airway obstruction or injury.
D. Take measures to prevent injury: The priority during a seizure is to protect the client from injury by ensuring a safe environment, such as padding the head and moving any dangerous objects away.
Correct Answer is D
Explanation
A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.
B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.
C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.
D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.
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