A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?
Initiate a calorie count of daily food intake.
Provide food in a thin liquid consistency.
Instruct the client to keep their chin up when swallowing.
Place the client in a semi-Fowler's position when eating.
The Correct Answer is D
Choice A rationale:
Initiating a calorie count of daily food intake is not directly related to addressing dysphagia. Calorie counts might be important in certain situations, such as managing weight, but it does not directly address the client's swallowing difficulties.
Choice B rationale:
Providing food in a thin liquid consistency is contraindicated for a client with dysphagia. Thin liquids can increase the risk of aspiration in individuals with swallowing difficulties. The nurse should choose thicker liquids and modify the diet as recommended by a speech-language pathologist or healthcare provider.
Choice C rationale:
Instructing the client to keep their chin up when swallowing is not an appropriate action for addressing dysphagia. Instead, clients with dysphagia are often instructed to tuck their chin down to their chest when swallowing. This helps to close off the airway and prevents food or liquids from entering the airway.
Choice D rationale:
Placing the client in a semi-Fowler's position when eating is the correct action. This position helps prevent aspiration by promoting proper alignment of the airway and esophagus. The semi-Fowler's position involves elevating the head of the bed to an angle of 30-45 degrees. This position facilitates swallowing and reduces the risk of choking or aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Total albumin is a valuable indicator of a client's nutritional status, but it has a longer half-life and is slower to reflect short-term changes. It may not accurately reflect the immediate effectiveness of total parenteral nutrition (TPN).
Choice B rationale:
Transferrin is a protein that transports iron in the body and is often used to assess iron deficiency. It is not a specific indicator of the effectiveness of TPN in the short term.
Choice C rationale:
Hemoglobin is a protein found in red blood cells and is responsible for oxygen transport. While it can be affected by nutritional status, it is not the most specific indicator of the effectiveness of TPN in the short term.
Choice D rationale:
Prealbumin (also known as transthyretin) is the best indicator for the nurse to monitor for the short-term effectiveness of TPN. Prealbumin has a short half-life of approximately 2 days, making it sensitive to changes in nutritional status and response to TPN. A decrease in prealbumin levels indicates inadequate nutritional support, while an increase suggests improved nutritional intake.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I can choose an avocado dip instead of salsa," indicates an understanding of the teaching about a low-saturated fat diet. Avocado is a source of healthy monounsaturated fats, which are preferred over saturated fats. This choice aligns with the goal of reducing saturated fat intake, which is important for cardiovascular health. Avocado dip is a better choice than salsa in this context due to its healthier fat content.
Choice B rationale:
The statement "I can eat the skin on poultry if it is broiled" is not indicative of an understanding of a low-saturated fat diet. Poultry skin is high in saturated fat, and even though broiling is a healthier cooking method compared to frying, the saturated fat content in the skin remains a concern.
Choice C rationale:
The statement "I will use margarine on my waffles" is not aligned with the teaching of a low-saturated fat diet. Most margarines contain trans fats or unhealthy saturated fats, which can be detrimental to cardiovascular health. Using margarine on waffles would likely contribute to the intake of unhealthy fats.
Choice D rationale:
The statement "I will include 7 ounces of fish in my diet weekly" does not reflect an understanding of a low-saturated fat diet. While fish is generally a healthy protein source, this statement doesn't specifically address saturated fat reduction. The type of fish and its preparation method can influence the saturated fat content, so simply including a certain amount of fish does not guarantee adherence to a low-saturated fat diet.
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