A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?
Rapid chewing
Garbled voice
Sneezing
Increased hunger
The Correct Answer is B
A. Rapid chewing.: Rapid chewing is not typically a manifestation of dysphagia. Dysphagia often involves difficulty swallowing rather than chewing.
B. Garbled voice.: A garbled voice can be a sign of dysphagia, especially if the client has difficulty coordinating their speech and swallowing muscles. This can occur when there is impaired motor control following a stroke.
C. Sneezing.: Sneezing is not related to dysphagia. Dysphagia is characterized by difficulty swallowing rather than respiratory symptoms.
D. Increased hunger.: Increased hunger is not a symptom of dysphagia. Dysphagia primarily involves difficulty with swallowing rather than changes in appetite.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide the teaching without expecting the client to respond: This approach does not address the client’s communication difficulties and may not effectively assess the client’s understanding or ability to interact.
B. Determine the client's ability to use a communication board: A communication board can assist clients with expressive aphasia in conveying their needs and understanding, making it a helpful tool for interaction.
C. Speak with a loud voice while providing the information: Expressive aphasia affects the ability to speak, not the ability to hear. Speaking loudly does not aid in comprehension or communication.
D. Avoid the use of facial gestures during the instructions: Facial gestures and non-verbal communication can support understanding and should not be avoided; they can be particularly helpful for clients with expressive aphasia.
Correct Answer is D
Explanation
A. Apply the belt restraint over the client's gown: The restraint should be applied directly to the client’s body to prevent movement, not over clothing, which can be ineffective and uncomfortable.
B. Check the client's skin integrity every 4 hr: Skin integrity should be checked more frequently, typically every 1-2 hours, to prevent skin breakdown and ensure the client’s safety.
C. Tie the belt restraint to the side rail of the bed: The restraint should be tied to the moveable part of the bed, not the side rail, to ensure that the restraint does not tighten when the bed is adjusted.
D. Make sure four fingers fit between the restraint and the client's body: This ensures proper fitting and comfort, preventing the restraint from being too tight or causing injury.
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