A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.

Which of the following instructions should the nurse include?

Encourage brief exercise before meals to promote appetite.

Place the client with the head reclined back to facilitate swallowing.

Encourage the client to take small bites.

Place food in the affected side of the mouth.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.

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Correct Answer is B

Explanation

Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.

A. Distended bladder. B. Dysuria. C. Report of feeling pressure. D. Voiding 30 mL frequently. E. Tenderness over the symphysis pubis.

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.

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A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns on the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention.

Correct Answer is B

Explanation

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Correct Answer is ["A","C","D","E"]

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A nurse is instructing a client's family members about feeding safety for a client who has dysphagia following a stroke.

Which of the following instructions should the nurse include?