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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Remaining flat in bed post-thoracentesis can impair respiratory function by reducing lung expansion. Proper positioning facilitates pleural fluid clearance and reduces dyspnea risk. Elevating the head enhances ventilation and drainage, improving post-procedural recovery and minimizing complications.
Choice B rationale
Post-procedure chest x-rays confirm successful fluid removal and monitor for complications like pneumothorax, common after pleural interventions. Imaging validates lung re-expansion and ensures pleural integrity, critical for addressing new or worsening respiratory distress symptoms.
Choice C rationale
Aseptic, not clean technique, minimizes infection risk during thoracentesis. Sterile precautions protect against bacterial introduction into the pleural space, which can cause empyema, a severe complication. All materials and the procedure field should meet sterile standards.
Choice D rationale
Urinary catheter insertion is unrelated to thoracentesis and poses unnecessary infection risks. The procedure focuses on resolving pleural fluid issues, and urinary monitoring is not standard unless clinically indicated for other medical concerns. .
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.
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