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. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.
B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.
C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.
D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.
Correct Answer is C
Explanation
A. Random, rapid growth of the tumor: Benign tumors generally grow slowly and are less likely to invade nearby tissues. Rapid growth is more characteristic of malignant tumors.
B. Cells colonizing to distant body parts: Benign tumors do not metastasize to distant parts of the body; this is a feature of malignant tumors.
C. Tumor pressure against normal tissues: Even though benign tumors do not invade other tissues, they can still cause problems by pressing against surrounding normal tissues, potentially leading to significant functional issues depending on their location.
D. Emission of abnormal proteins: Abnormal protein emission is more relevant to malignancies that may cause paraneoplastic syndromes rather than benign tumors.
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