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 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.
Correct Answer is D
Explanation
A. “I don’t take naps throughout the day.”
This statement suggests that the client avoids daytime napping, which is generally a positive sleep habit. Excessive daytime napping can interfere with nighttime sleep.
B. “I go to bed and get up at the same times each day.”
Maintaining a consistent sleep schedule is a key component of good sleep hygiene. Going to bed and waking up at the same times helps regulate the body's internal clock.
C. “I have a small snack and take a bath before going to bed each day.”
Having a light snack and engaging in a relaxing activity like a bath before bedtime can contribute to a more conducive sleep environment. However, the type and timing of the snack should be considered.
D. “I watch television until I fall asleep at night.”
This statement may indicate a need for further instruction. Watching television right before bedtime, especially until falling asleep, can be counterproductive to good sleep hygiene due to the stimulating effects of the screen's blue light.
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