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.
Encourage the client to take small bites.
Place the client with the head reclined back to facilitate swallowing.
Place food in the affected side of the mouth.
The Correct Answer is B
Choice A reason: Encourage brief exercise before meals to promote appetite. This answer is incorrect because exercise before meals can increase fatigue and decrease appetite in some clients with dysphagia. Exercise can also affect the blood flow to the brain and the muscles involved in swallowing .
Choice B reason: Encourage the client to take small bites. This answer is correct because taking small bites can help the client swallow more easily and reduce the risk of choking or aspiration.
Choice C reason: Place the client with the head reclined back to facilitate swallowing. This answer is incorrect because placing the client with the head reclined back can impair the swallowing mechanism and increase the risk of aspiration. The client should be placed with the head tilted slightly forward to help the food move down the throat.
Choice D reason: Place food in the affected side of the mouth. This answer is incorrect because placing food in the affected side of the mouth can cause the food to remain in the mouth and not be swallowed properly. The client should be encouraged to use both sides of the mouth to chew and swallow food.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Droplet precautions are not appropriate for a client who has tuberculosis and a productive cough. Droplet precautions are used to prevent the transmission of infectious agents that are spread by large respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions require the use of a surgical mask, eye protection, and gloves when in close contact with the client.
Choice B reason: Protective precautions are not applicable for a client who has tuberculosis and a productive cough. Protective precautions are used to protect immunocompromised clients from exposure to pathogens, such as those undergoing chemotherapy, organ transplantation, or stem cell transplantation. Protective precautions require the use of a HEPA filter, a positive pressure room, and a mask for the client when leaving the room.
Choice C reason: Contact precautions are not sufficient for a client who has tuberculosis and a productive cough. Contact precautions are used to prevent the transmission of infectious agents that are spread by direct or indirect contact with the client or the client's environment, such as Clostridioides difficile, MRSA, or VRE. Contact precautions require the use of gloves and gowns when entering the room and the dedicated use of noncritical patientcare equipment.
Choice D reason: Airborne precautions are the correct type of isolation precautions for a client who has tuberculosis and a productive cough. Airborne precautions are used to prevent the transmission of infectious agents that are spread by small respiratory droplets that can remain suspended in the air, such as tuberculosis, measles, or chickenpox. Airborne precautions require the use of a respirator, such as an N95 mask, a negative pressure room, and a mask for the client when leaving the room.
Correct Answer is A
Explanation
Choice A reason: The oral mucosa is the most reliable indicator of central cyanosis because it reflects the oxygen saturation of the arterial blood. Central cyanosis occurs when the arterial blood has a low oxygen saturation due to a cardiopulmonary problem. The oral mucosa is less affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation.
Choice B reason: The conjunctivae are not a reliable indicator of central cyanosis because they can be affected by other conditions such as anemia, jaundice, or eye infections. The conjunctivae are the thin membranes that cover the white part of the eye and the inner surface of the eyelids.
Choice C reason: The ear lobes are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The ear lobes are the fleshy lower part of the external ear.
Choice D reason: The soles of the feet are not a reliable indicator of central cyanosis because they can be affected by peripheral factors such as temperature, vasoconstriction, or skin pigmentation. The soles of the feet are the bottom part of the feet.
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