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 D

Explanation

A. Use a washcloth to clean the denture surfaces: Dentures should be cleaned using a soft-bristled toothbrush or denture brush to effectively remove food particles and plaque. A washcloth is not effective for thoroughly cleaning denture surfaces.
B. Floss dentures as part of daily cleaning: Flossing is intended for natural teeth, not dentures. Dentures require brushing and soaking, but do not have spaces between teeth that need flossing.
C. Wipe dentures before storing them in a dry container at night: Dentures should be stored in water or a denture solution overnight to prevent them from drying out and warping. Keeping them in a dry container is incorrect.
D. Wrap gloved fingers with gauze to remove dentures: Wrapping gloved fingers with gauze provides a better grip and reduces the risk of injury or dropping the dentures during removal. This is the appropriate technique when assisting with denture care.

A. "Small frequent snacks can help prevent a drop in glucose." B. "Make sure to hydrate with your meals." C. "It is okay if you need to skip some meals." D. "Hard candy is an appropriate snack." E. "Consume large meals to provide adequate calories." F. "Ginger tea may help settle your stomach." G. "Eat crackers before getting out of bed in the morning."

Correct Answer is ["A","D","F","G"]

Explanation

A. "Small frequent snacks can help prevent a drop in glucose." Frequent, small meals help stabilize blood glucose levels and reduce the risk of nausea due to an empty stomach. They also promote consistent calorie intake when appetite is reduced during early pregnancy.
B. "Make sure to hydrate with your meals." Drinking fluids with meals can increase gastric fullness and make nausea worse. It's often better to drink fluids between meals to avoid bloating and help control symptoms.
C. "It is okay if you need to skip some meals." Skipping meals may lead to hypoglycemia, which can intensify nausea and fatigue. Maintaining a steady intake of food, even in small amounts, supports maternal and fetal well-being.
D. "Hard candy is an appropriate snack." Sucking on hard candy can help reduce nausea by stimulating saliva production and masking unpleasant tastes. It can also serve as a quick source of energy between meals.
E. "Consume large meals to provide adequate calories." Large meals may worsen nausea by distending the stomach. Smaller, frequent meals are better tolerated and still provide sufficient nutrition over the course of the day.
F. "Ginger tea may help settle your stomach." Ginger has been shown to reduce mild to moderate nausea during pregnancy. Ginger tea offers a safe and natural way to soothe the stomach without the use of medications.
G. "Eat crackers before getting out of bed in the morning." Eating bland foods like crackers before rising helps prevent an empty stomach, which often triggers morning sickness. This simple routine can reduce nausea on waking.

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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

Naxlex Comprehensive Predictor Exams

A nurse is teaching about denture care to the partner of a client who is unable to perform oral hygiene. Which of the following should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client at a provider's office. Exhibits Select 4 statements the nurse should plan to include when providing teaching to the client.

Correct Answer is ["A","D","F","G"]

Explanation

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