A nurse is caring for a client who had a stroke and has manifestations of dysphagia. Which of the following interventions should the nurse take?
Use liquids to clear food from the client's mouth.
Tilt the client's head backwards to facilitate swallowing.
Add a thickening agent to liquids.
Place the client in a semi-Fowler's position.
The Correct Answer is C
Choice A reason: Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.
Choice B reason: Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.
Choice C reason: Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.
Choice D reason: Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice Areason: Graham crackers are made from wheat flour, which contains gluten. Peanut butter is a good source of fat and protein, but it may also contain traces of gluten from cross-contamination.
Choice Breason: Poached eggs are a good source of protein, but wheat bagel contains gluten, which is a protein found in wheat, barley, and rye. Gluten can damage the small intestine and cause malabsorption, diarrhea, and abdominal pain in people with celiac disease.
Choice C reason: Rice cereal is gluten-free and a good source of carbohydrates. Sliced bananas are gluten-free and a good source of potassium, fiber, and vitamin C.
Choice D reason: Rye toast contains gluten, which can harm people with celiac disease. Herbal tea is gluten-free and can help with hydration, but it does not provide enough calories or nutrients.
Correct Answer is B
Explanation
Choice A reason: Applying ice packs for 15 minutes every hour is not an effective intervention for managing edema following knee replacement surgery because it can impair blood circulation and delay healing. Ice packs can also cause frostbite or nerve damage if applied for too long or too frequently. Ice packs should be used only for the first 24 to 48 hours after surgery and with a cloth barrier between the skin and the ice.
Choice B reason: Elevating the affected leg above the heart level is an effective intervention for managing edema following knee replacement surgery because it can reduce swelling and pain by facilitating venous return and lymphatic drainage. Elevation can also prevent blood clots and infection by improving blood flow and oxygen delivery to the wound site.
Choice C reason: Consuming nutrition-dense foods first is not a relevant intervention for managing edema following knee replacement surgery because it does not directly affect fluid balance or wound healing. Nutrition-dense foods are those that provide high amounts of nutrients per serving, such as eggs, cheese, nuts, beans, and meat. Nutrition-dense foods are important for overall health, but not specifically for edema management.
Choice D reason: Wearing compression stockings during the day is not a recommended intervention for managing edema following knee replacement surgery because it can interfere with wound healing and increase the risk of infection. Compression stockings can also cause skin irritation, blisters, or ulcers if worn incorrectly or too tightly. Compression stockings should be avoided until the wound is fully healed and only used under medical supervision.
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