A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

Offer liquids frequently, in large quantities

Allow optimum physical activity before meals to expedite digestion

Help the client sit upright when eating and feed slowly

Instruct the client to lie on the bed when eating

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: Offering large quantities of liquids frequently increases aspiration risk in clients with dysphagia from neurological disorders. Large volumes can overwhelm swallowing mechanisms, leading to choking or pneumonia. Controlled, small sips with proper positioning are safer to ensure nutrition without compromising airway safety.

Choice B reason: Allowing physical activity before meals may improve appetite but does not address swallowing difficulties. Activity does not facilitate safe swallowing in neurological disorders, where muscle coordination is impaired. Proper positioning and pacing during feeding are more effective to prevent aspiration and ensure nutritional intake.

Choice C reason: Helping the client sit upright and feeding slowly minimizes aspiration risk in neurological dysphagia. Upright positioning aligns the airway to prevent food or liquid entry, and slow feeding allows better coordination of swallowing muscles, reducing choking and ensuring adequate nutrition, critical for safe intake.

Choice D reason: Instructing the client to lie down while eating is dangerous in dysphagia, as it increases aspiration risk. Lying down allows food or liquids to enter the airway, potentially causing pneumonia. Upright positioning is essential to facilitate safe swallowing and prevent complications in neurological disorders.

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Correct Answer is B

Explanation

Reasoning:

Choice A reason: Taking iron with meals reduces gastrointestinal upset but does not prevent tooth staining. Food may decrease iron absorption by binding to dietary components, but it has no direct effect on preventing contact between liquid iron preparations and teeth, which causes staining.

Choice B reason: Diluting liquid iron preparations with juice and drinking through a straw minimizes contact with teeth, preventing staining. Iron can bind to enamel, causing discoloration, and using a straw directs the solution past the teeth, reducing exposure while juice dilutes the concentration, protecting dental health.

Choice C reason: Avoiding combining iron with other medications prevents absorption interactions but does not address tooth staining. Certain drugs, like tetracycline, may interact with iron, but this is unrelated to the enamel discoloration caused by direct contact with liquid iron preparations.

Choice D reason: Avoiding antacids with iron prevents reduced absorption, as antacids increase gastric pH, impairing iron solubility. However, this does not prevent tooth staining, which occurs from direct contact of liquid iron with enamel, making this action irrelevant to the goal of dental protection.

A. Seizures B. Septicemia C. Bleeding D. Acute pain

Correct Answer is C

Explanation

Reasoning:

Choice A reason: Seizures can occur post-stroke due to cortical irritation, but they are not the primary complication of t-PA. Thrombolytics increase bleeding risk, particularly intracranial hemorrhage, which is more immediate and life-threatening, making seizure monitoring secondary to vigilant observation for bleeding signs.

Choice B reason: Septicemia is not a direct complication of t-PA or ischemic stroke. While infections may occur later due to immobility or hospitalization, t-PA’s primary risk is bleeding due to its fibrinolytic action, making septicemia a less urgent concern in the immediate post-treatment period.

Choice C reason: Bleeding, particularly intracranial hemorrhage, is the most critical complication to monitor post-t-PA in ischemic stroke. t-PA dissolves clots, increasing the risk of bleeding in the brain or other sites, which can lead to neurological deterioration or death, requiring close monitoring in the ICU.

Choice D reason: Acute pain is not a primary complication of t-PA or ischemic stroke. Pain may occur in stroke from spasticity or other causes, but bleeding is the most immediate and severe risk of thrombolytic therapy, requiring prioritized monitoring over pain assessment.

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A client with a neurological disorder has difficulty swallowing. The nurse should take special care with the client’s diet because of a potential risk of imbalanced nutrition. Which measure may be taken by the nurse to ensure that the client’s diet allows for easy swallowing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should advise a client with iron deficiency anemia to take which action to prevent staining of the teeth?

Correct Answer is B

Explanation

A client with a new diagnosis of ischemic stroke was treated in the ED with tissue plasminogen activator (t-PA) and then admitted to the ICU. In addition to closely monitoring the client’s cardiac and neurologic status, the nurse monitors the client for signs of what complication?

Correct Answer is C

Explanation

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