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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F","G"]
Explanation
A. "I should drink about 80 ounces of fluid per day." Adequate hydration is essential for clients with colostomies to prevent constipation and support optimal bowel function. A daily fluid intake of around 80 ounces helps maintain stool consistency and supports overall digestion.
B. "I should eat a source of protein at each meal and snack." Protein is vital for healing, tissue repair, and maintaining muscle mass following surgery. Including protein in meals and snacks supports recovery and meets increased metabolic demands postoperatively.
C. "I should chew my food thoroughly." Thorough chewing reduces the risk of large, undigested food particles entering the stoma, which can cause blockages. This practice promotes better digestion and safer colostomy management.
D. “I should take an over-the-counter antidiarrheal medication if my stools are semiliquid." Using antidiarrheal medication without provider direction may mask underlying complications or contribute to improper bowel regulation. Medical guidance is necessary before initiating any such treatment.
E. "I will have trouble digesting food due to the colostomy." A colostomy changes stool elimination but does not impair digestion or nutrient absorption. The digestive process remains largely intact unless there are additional gastrointestinal conditions.
F. “I should eat 4 to 6 small meals per day." Small, frequent meals promote steady digestion, reduce gas formation, and help clients maintain energy levels during recovery. This pattern is also easier to tolerate postoperatively.
G. "I should eat high-fiber foods." Fiber intake helps regulate bowel movements and promotes stool formation. High-fiber foods should be reintroduced gradually to prevent gas or blockage, especially in the early weeks post-surgery.
H. “I should eat nuts for the first 2 weeks following surgery as a source of fiber." Nuts are difficult to digest and may cause stoma blockage during the early recovery phase. Clients are advised to avoid hard or high-residue foods initially and introduce them gradually under provider supervision.
Correct Answer is C
Explanation
A. "Make sure to drink water with your meals." While staying hydrated is important for metabolism and satiety, emphasizing water intake with meals over other proven strategies, like portion control and meal timing, may not be the most effective behavioral focus for weight loss education.
B. "Meal replacement shakes can cause weight gain." Stating that meal replacement shakes can cause weight gain can be misleading. Weight gain typically occurs when total caloric intake exceeds expenditure, regardless of whether calories come from shakes or food.
C. "Your biggest meal of the day should be breakfast." Eating a larger breakfast can promote weight loss by jump-starting metabolism and reducing overall calorie intake later in the day. Front-loading calories earlier in the day can improve satiety and energy levels, leading to healthier eating patterns and potentially better adherence to weight loss goals.
D. "Set your weight loss goal to 2.5 pounds per week." A safe and sustainable weight loss goal is typically 1 to 2 pounds per week. A goal of 2.5 pounds per week may be too aggressive and unrealistic for most individuals, increasing the risk of muscle loss, nutritional deficiencies, or rebound weight gain. Encouraging gradual, steady weight loss supports long-term success.
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