A nurse is caring for a client who has dysphagia following a stroke.
When assisting the client at mealtime, which of the following actions should the nurse plan to take?

Instruct the client to tilt their head back to facilitate swallowing.

Schedule physical therapy directly before meals.

Provide oral care before meals.

Encourage the client to use a straw.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Instructing the client to tilt their head back increases the risk of aspiration by misaligning the airway and esophagus. Clients with dysphagia require strategies that minimize the risk of aspiration and promote safe swallowing, such as a neutral head position or chin tuck.

Choice B rationale

Scheduling physical therapy directly before meals is inappropriate as it may cause fatigue, reducing the client’s ability to eat safely. Proper scheduling ensures clients have sufficient energy to focus on eating, essential for minimizing aspiration risks in those with dysphagia.

Choice C rationale

Providing oral care before meals reduces the bacterial load in the oral cavity, lowering the risk of aspiration pneumonia if food or liquids are accidentally aspirated. Maintaining good oral hygiene is a key preventive measure for complications related to dysphagia.

Choice D rationale

Encouraging the use of a straw is contraindicated as it can increase the risk of aspiration. Using a straw can direct liquids forcefully to the throat, overwhelming the client’s ability to control swallowing, which is a safety concern for individuals with dysphagia.

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Correct Answer is A

Explanation

Choice A rationale

Scheduled bathroom trips promote bladder retraining by establishing a pattern, enhancing control in clients with urinary incontinence. Bladder retraining encourages the bladder to hold more urine over time by following a structured toileting schedule, reducing incontinence frequency.

Choice B rationale

Limiting fluids before bedtime minimally affects urinary incontinence and can lead to insufficient hydration, resulting in more concentrated urine, which may irritate the bladder and increase urgency sensations.

Choice C rationale

Coffee contains caffeine, a diuretic, and bladder irritant that exacerbates incontinence symptoms by stimulating bladder contractions and increasing urinary frequency. Limiting caffeine is recommended for such clients.

Choice D rationale

Indwelling catheters are not generally recommended for bladder management due to their risks, including urinary tract infections and mechanical irritation. Non-invasive approaches are preferred for long-term urinary incontinence management.

A. Provide a high-calorie diet. B. Encourage three large meals daily. C. Administer an antiemetic after each meal. D. Include seasonings with spices in meals.

Correct Answer is A

Explanation

Choice A rationale

A high-calorie diet is crucial for clients with AIDS and malnutrition to meet the increased metabolic demands caused by the disease and to compensate for nutrient deficiencies. Proper nutrition supports immune function and aids in maintaining muscle mass and energy levels, which are often compromised in malnourished clients.

Choice B rationale

Encouraging three large meals daily may not be appropriate, as clients with AIDS and malnutrition often experience gastrointestinal discomfort, nausea, or early satiety. Smaller, more frequent meals are typically better tolerated and can improve overall nutritional intake compared to larger meals.

Choice C rationale

Administering an antiemetic after each meal may help reduce nausea and improve food intake in some cases. However, this action should be based on the client's specific needs and symptoms. It is not a universal intervention for malnutrition in clients with AIDS and does not directly address the need for adequate calorie intake.

Choice D rationale

Including seasonings and spices may enhance the flavor of meals and encourage food intake. However, strong spices can sometimes exacerbate gastrointestinal symptoms in clients with AIDS. This action is not as effective or essential as providing a high-calorie diet to address malnutrition.

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A nurse is caring for a client who has dysphagia following a stroke.When assisting the client at mealtime, which of the following actions should the nurse plan to take?

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A nurse is caring for a client who has dysphagia following a stroke.
When assisting the client at mealtime, which of the following actions should the nurse plan to take?