A nurse is caring for a client who had a stroke and is drooling. Which of the following actions should the nurse take first?

Offer the client thickened liquids to drink.

Monitor the client for indications of fatigue during meals.

Check the client's gag reflex.

Monitor the client's ability to speak consistently.

Answer and Explanation

The Correct Answer is C

A. Offer the client thickened liquids to drink: Offering thickened liquids can help reduce the risk of aspiration in clients with dysphagia, which is common after a stroke. However, this should be done after confirming that the client has a safe swallowing mechanism, such as an intact gag reflex. Administering liquids before assessing swallowing safety can increase the risk of aspiration pneumonia.
B. Monitor the client for indications of fatigue during meals: Fatigue can compromise the client’s ability to chew and swallow effectively, increasing the risk of aspiration. Monitoring for this is important but is not the immediate priority when the client is already drooling, a sign that they may be unable to manage their oral secretions. Ensuring safe swallowing should be addressed before monitoring meal-time fatigue.
C. Check the client's gag reflex: Checking the gag reflex is the most important initial action because it directly assesses the client’s ability to swallow safely. Drooling after a stroke often indicates impaired neuromuscular control, which puts the client at high risk for aspiration. The gag reflex gives immediate information on whether oral intake is safe.
D. Monitor the client's ability to speak consistently: Monitoring speech consistency can provide insights into neurological recovery and motor control, but it is not the first concern in a drooling stroke patient. The primary danger is aspiration due to impaired swallowing. Speaking ability does not directly reflect swallowing safety.

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Correct Answer is A

Explanation

A. "I use soup broth instead of butter to flavor food.": This reflects a positive dietary change aimed at reducing saturated fat and sodium intake, both important in managing hypertension. Using broth adds flavor without the added fat and calories of butter, supporting heart health.
B. "I have started cooking most of my meals.": While home-cooked meals can promote healthier eating, the nutritional value depends on the ingredients and methods used. This statement alone does not confirm whether low-sodium or low-fat cooking practices are being followed.
C. "I eat cheese cubes and crackers as snack.": Cheese and many crackers are high in sodium and saturated fats, which can worsen hypertension. This snack choice suggests the client has not yet adopted heart-healthy dietary practices recommended during counseling.
D. "I add canned vegetables to my homemade soup.": Canned vegetables often contain high amounts of sodium unless labeled low-sodium or rinsed before use. Including them without modifications could increase salt intake and negatively affect blood pressure management.

A. "I will eat something when I feel hungry." B. "I will peel apples before I eat them." C. "I will eliminate carbohydrates from my diet." D. "I will use corn oil when frying foods."

Correct Answer is A

Explanation

A. "I will eat something when I feel hungry." Responding to true physical hunger is a principle of mindful eating, which supports weight loss by preventing overeating due to emotional or external cues. Recognizing and honoring hunger promotes better portion control and sustainable eating habits.
B. "I will peel apples before I eat them." Apple peels contain fiber, which increases satiety and supports digestive health. Removing the peel reduces fiber content, which may make the snack less filling and hinder weight management efforts.
C. "I will eliminate carbohydrates from my diet." Eliminating carbohydrates completely is not recommended for healthy weight loss. Balanced diets that include whole grains, fruits, and vegetables support long-term weight management and provide essential nutrients.
D. "I will use corn oil when frying foods." Frying foods, regardless of the type of oil, increases calorie density and may not support weight loss. Healthier cooking methods like baking, steaming, or grilling are preferred for reducing fat intake and promoting weight control.

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A nurse is caring for a client who had a stroke and is drooling. Which of the following actions should the nurse take first?

Nursing Test Bank

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