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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Clean the perineum from front to back.

After arranging the sterile items, the next step involves preparing the client for catheter insertion, which includes cleaning the perineum from front to back using appropriate techniques to minimize the risk of infection.

B. Lubricate the catheter.

Following the preparation of the client, the next step involves lubricating the catheter before insertion. Lubrication facilitates the smooth and atraumatic insertion of the catheter.

C. Explain to the client that she will feel temporary discomfort.

Providing information and preparing the client for the procedure is an important aspect, but it typically follows the physical preparation steps. Explaining to the client about potential discomfort should be done before the procedure but after the necessary physical preparations are complete.

D. Arrange the sterile items on the sterile field.

This is the first action to be taken. It involves preparing all the necessary sterile items on a sterile field, ensuring that everything needed for the catheter insertion procedure is organized and ready to maintain aseptic technique.

A. “Increase your caloric intake by eating foods high in protein.” B. “Include fresh fruits and vegetables at each meal.” C. “Maintain your weight by eating high fat foods.” D. “Drink whole milk to ensure adequate calcium intake.”

Correct Answer is A

Explanation

A. “Increase your caloric intake by eating foods high in protein.”

This is the appropriate choice. Increasing caloric intake with high-protein foods can help meet nutritional needs for individuals with Crohn's Disease, especially if malabsorption is a concern.

B. “Include fresh fruits and vegetables at each meal.”

While fresh fruits and vegetables are generally healthy, they may exacerbate symptoms in some individuals with Crohn's Disease, especially during flare-ups. It may be advisable to choose cooked or processed fruits and vegetables to minimize irritation.

C. “Maintain your weight by eating high-fat foods.”

This statement is not advisable. High-fat foods can contribute to symptoms such as cramping and diarrhea in individuals with Crohn's Disease. A well-balanced diet with an appropriate mix of nutrients is generally recommended.

D. “Drink whole milk to ensure adequate calcium intake.”

This statement is not advisable without considering individual tolerance. Whole milk is high in fat and may be difficult to digest for some individuals with Crohn's Disease. Additionally, if lactose intolerance is present, it may worsen symptoms. Alternative sources of calcium may need to be considered.

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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?

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