A nurse is planning care for a client who had a stroke and is having difficulty eating. Which of the following interventions should the nurse include in the plan?

Place the head of the client's bed to 30° for meals.

Encourage the client to chew on both sides of their mouth.

Describe food locations as if the client's plate were a clock.

Provide the client with wide-grip adaptive utensils.

Answer and Explanation

The Correct Answer is C

A. Place the head of the client's bed to 30° for meals: Elevating the head of the bed to 30° is not sufficient to prevent aspiration in a client who has difficulty eating after a stroke. A 90° angle or as high as tolerated is typically recommended during meals to reduce the risk of aspiration and ensure safe swallowing. A lower elevation increases the chance of food or liquid entering the airway.
B. Encourage the client to chew on both sides of their mouth: Clients who have had a stroke often experience unilateral weakness, including facial and oral muscle weakness. Encouraging them to chew on both sides may not be feasible and can increase the risk of choking if one side of the mouth is significantly paralyzed. Instead, focusing on the stronger side for chewing is safer.
C. Describe food locations as if the client's plate were a clock: This technique is especially helpful for clients with visual field deficits, such as hemianopia, which is common after a stroke. Describing food using the clock method helps orient the client to the location of items on the plate, promoting independence and reducing frustration during meals.
D. Provide the client with wide-grip adaptive utensils: Wide-grip adaptive utensils are beneficial for clients with impaired fine motor skills or limited hand strength, which may occur after a stroke. However, while helpful, this intervention does not directly address the primary issue of difficulty eating due to perceptual or cognitive deficits.

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Correct Answer is A

Explanation

A. Record between-meal snacks on the calorie count form: Between-meal snacks contribute significantly to a client's total daily caloric intake and must be included to obtain an accurate calorie count. Omitting these snacks can result in an incomplete dietary assessment, potentially leading to inaccurate evaluations of the client's nutritional status.
B. Begin the calorie count with the client's next evening meal: Calorie counts should begin as soon as the prescription is initiated, not delayed until a specific mealtime. Waiting to begin with the evening meal may result in missed intake data and reduce the accuracy of the assessment. Timely initiation ensures the healthcare team captures a complete and accurate picture of the client’s intake patterns.
C. Exclude liquids in the total calorie count: Liquids, especially those containing calories such as juice, milk, nutritional supplements, or sweetened beverages, must be included in a calorie count. Excluding these items can underestimate the client’s actual caloric intake and interfere with proper evaluation and planning of their nutritional needs.
D. Complete the calorie count for a 5-day period: A standard calorie count is typically conducted over a 72-hour (3-day) period, which is sufficient to identify trends and provide nutritional insights. Extending the count unnecessarily to 5 days may not yield additional useful data and can burden both clients and staff. The focus should be on consistency and completeness within the accepted timeframe.

A. "Make sure to drink water with your meals." B. "Meal replacement shakes can cause weight gain." C. “Your biggest meal of the day should be breakfast." D. "Set your weight loss goal to 2.5 pounds per week."

Correct Answer is C

Explanation

A. "Make sure to drink water with your meals." While staying hydrated is important for metabolism and satiety, emphasizing water intake with meals over other proven strategies, like portion control and meal timing, may not be the most effective behavioral focus for weight loss education.
B. "Meal replacement shakes can cause weight gain." Stating that meal replacement shakes can cause weight gain can be misleading. Weight gain typically occurs when total caloric intake exceeds expenditure, regardless of whether calories come from shakes or food.
C. "Your biggest meal of the day should be breakfast." Eating a larger breakfast can promote weight loss by jump-starting metabolism and reducing overall calorie intake later in the day. Front-loading calories earlier in the day can improve satiety and energy levels, leading to healthier eating patterns and potentially better adherence to weight loss goals.
D. "Set your weight loss goal to 2.5 pounds per week." A safe and sustainable weight loss goal is typically 1 to 2 pounds per week. A goal of 2.5 pounds per week may be too aggressive and unrealistic for most individuals, increasing the risk of muscle loss, nutritional deficiencies, or rebound weight gain. Encouraging gradual, steady weight loss supports long-term success.

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