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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Moist mucous membranes: While moist mucous membranes may indicate adequate hydration, they are not specific to the treatment of hypocalcemia. The goal of hypocalcemia treatment is to correct calcium levels in the body, which would be reflected by the resolution of clinical signs related to low calcium, such as Chvostek's sign.
B. Negative Chvostek's sign: Chvostek's sign is a clinical sign that suggests hypocalcemia, where tapping the facial nerve causes twitching of the facial muscles. A negative Chvostek's sign indicates that calcium levels have normalized, meaning the treatment for hypocalcemia has been effective. The absence of this sign is a reliable indicator that the treatment has corrected the calcium deficiency.
C. Weight gain: Weight gain is not a typical or direct indicator of hypocalcemia treatment success. While some treatments for hypocalcemia might impact overall metabolism, weight gain is not a specific or reliable sign of calcium normalization. The most relevant sign would be the absence of symptoms related to calcium deficiency, such as a negative Chvostek’s sign.
D. Urine output 25 mL/hr: Urine output of 25 mL/hr is below the normal threshold, which is typically at least 30 mL/hr. While urine output can be affected by various factors, it is not a reliable marker for effective treatment of hypocalcemia. Treatment success is better assessed by signs related to calcium levels, such as the negative Chvostek’s sign, rather than urine output.
Correct Answer is A
Explanation
A. Keep total fat intake at 25% of calories per day. It is recommended that total fat intake be between 20% and 35% of daily calories, with an emphasis on healthy fats such as unsaturated fats from plant sources. Keeping fat intake around 25% supports cardiovascular health and balanced nutrition.
B. Limit cholesterol intake to 500 mg per day. The current recommendation is to limit dietary cholesterol to less than 300 mg per day. Excess cholesterol intake can increase the risk of cardiovascular disease, especially in individuals with other risk factors.
C. Consume 50% of daily food intake from protein. Protein should make up 10% to 35% of total daily calories. Consuming 50% from protein is excessive and may displace other essential nutrients like carbohydrates and healthy fats.
D. Restrict sodium intake to 3,000 mg per day. Recommended sodium intake for healthy adults is less than 2,300 mg per day. Lower limits are suggested for individuals with hypertension, kidney disease, or other related conditions to help manage blood pressure and fluid balance.
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