A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
Sit at or below the client's eye level during feedings.
Instruct the client to lift her chin when swallowing.
Talk with the client during her feeding.
Discourage the client from coughing during feedings.
The Correct Answer is A
Rationale:
A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.
B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.
C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.
D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Rationale:
A. "Alternate the shoes you wear each day.": Rotating shoes helps prevent pressure points and reduces the risk of skin breakdown or foot ulcers, which is important for clients with diabetes who have impaired circulation and sensation.
B. "Apply synthetic fabric socks.": Synthetic or moisture-wicking socks help keep feet dry and prevent fungal infections, a common concern in clients with diabetes. Cotton or synthetic blends are preferred over thick wool or socks that retain moisture.
C. "Wear open-toe shoes": Open-toe shoes increase the risk of injury, infection, and trauma, which can lead to serious complications in diabetic clients. Closed, well-fitting shoes provide protection and support.
D. "Wash your feet daily with warm water and soap": Daily washing and gentle drying of the feet helps maintain hygiene, prevents infection, and allows early detection of cuts, cracks, or sores. Warm, not hot, water prevents burns in clients with neuropathy.
E. "Soak your feet for 1 hour each day.": Prolonged soaking can cause skin maceration, increasing the risk of infection and breakdown. Soaking is generally discouraged for clients with diabetes.
Correct Answer is D
Explanation
Rationale:
A. Contraction intensity increased by ambulation: True labor contractions typically intensify with walking or activity, as the uterus works to dilate and efface the cervix. If contractions strengthen with movement, it suggests active labor rather than false labor.
B. Presence of bloody show: Bloody show indicates cervical changes with effacement and dilation, which are signs of true labor. Its presence helps differentiate true labor from false labor.
C. Slow change in dilation and effacement: True labor is characterized by progressive cervical change. Slow or minimal change in dilation and effacement is more consistent with false labor, but the primary hallmark is the nature of contractions.
D. Intermittent, painless contractions: False labor (Braxton Hicks contractions) is usually irregular, intermittent, and painless or minimally uncomfortable. They do not cause consistent cervical change and often subside with rest or position changes, making this a key distinguishing feature.
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