A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
Instruct the client to tilt her head back when she swallows.
Place food on the left side of the client’s mouth.
Add thickener to fluids.
Serve food at room temperature.
The Correct Answer is C
A. Instruct the client to tilt her head back when she swallows.
Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.
B. Place food on the left side of the client’s mouth.
Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.
C. Add thickener to fluids.
This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.
D. Serve food at room temperature.
While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Kidney beans
Kidney beans are a good plant-based source of protein. They contain essential amino acids, but plant-based proteins may lack some amino acids found in animal-based sources. While kidney beans contribute to protein intake, they are not considered the best source of protein for wound healing among the given options.
B. Grilled salmon
Grilled salmon is indicated as the best source of protein for wound healing among the options. Salmon is an animal-based source that provides high-quality protein with all essential amino acids. It is also rich in omega-3 fatty acids, which have anti-inflammatory properties and can further support the healing process.
C. Peanut butter
Peanut butter is a source of protein, but it is also high in fats. While it can contribute to protein intake, it may not be as lean a source as grilled salmon. It's important to consider the overall nutritional profile when recommending it for wound healing.
D. Raw spinach
Spinach is a source of protein, but it is considered a plant-based protein. While it can contribute to overall protein intake, plant-based proteins may not provide as much protein per serving as animal-based sources like salmon. It also contains other nutrients, such as iron and vitamins, which are beneficial but not specifically highlighted for wound healing in this context.
Correct Answer is A
Explanation
A. Apply a cool, wet compress to the affected area.
This action can help soothe the affected skin and reduce inflammation associated with eczema. It is important to avoid hot water, as it can further dry out the skin.
B. Launder clothing with fabric softener.
Fabric softeners can contain chemicals that may irritate sensitive skin. It is advisable to use mild, fragrance-free detergents and skip fabric softeners.
C. Give bubble baths every day.
Bubble baths can be drying to the skin, and frequent bathing may exacerbate eczema. It is recommended to keep baths short, use lukewarm water, and avoid harsh soaps.
D. Use wool gloves in the wintertime.
Wool can be irritating to sensitive skin, and for individuals with eczema, it's better to use soft, breathable fabrics for gloves to minimize irritation.
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