A nurse is providing dietary teaching for a client who has dysphagia. Which of the following instructions should the nurse include?
Cough between bites to clear the mouth
Talk while eating
Take sips of liquids while chewing food
Tilt the head back when swallowing
The Correct Answer is C
Choice A reason: Coughing between bites is not recommended because it can increase fatigue and does not effectively prevent aspiration. Instead, proper swallowing techniques and pacing are emphasized for clients with dysphagia.
Choice B reason: Talking while eating increases the risk of aspiration because it disrupts the coordination of breathing and swallowing. This is unsafe for clients with dysphagia.
Choice C reason: Taking sips of liquids while chewing food helps moisten the bolus, making swallowing easier and safer. It reduces the risk of food sticking in the throat and assists in clearing the airway. This is an appropriate teaching strategy for dysphagia management.
Choice D reason: Tilting the head back when swallowing increases the risk of aspiration because it opens the airway. The recommended technique is often chin-tuck, which narrows the airway and directs food toward the esophagus. Therefore, tilting the head back is unsafe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A positive Babinski reflex beyond 12 to 18 months is abnormal and indicates possible neurological dysfunction. At 15 months, the reflex should have disappeared as the nervous system matures. Persistence of this reflex suggests an upper motor neuron lesion or developmental delay, making it a reportable finding.
Choice B reason: The Moro reflex normally disappears by 4 months of age. Its absence at 15 months is expected and does not indicate abnormality.
Choice C reason: Referring to self by name is an appropriate developmental milestone for toddlers around 15 months. It reflects normal language and self-awareness development.
Choice D reason: Pointing to common objects when asked is a normal developmental milestone at this age, showing receptive language and cognitive development.
Correct Answer is B
Explanation
Choice A reason: White nits on the hair shaft indicate pediculosis capitis (head lice), not varicella. This finding is unrelated to viral infection and represents a parasitic infestation.
Choice B reason: Pruritic vesicles with an erythematous base are the hallmark of varicella (chickenpox). The rash typically begins on the face and trunk, progressing to limbs, and appears in successive crops. The vesicles are intensely itchy and evolve into pustules and crusts.
Choice C reason: Discolored pruritic warts on the feet and ankles are characteristic of human papillomavirus (HPV), not varicella. Warts are firm growths, not vesicular lesions.
Choice D reason: Koplik spots are pathognomonic for measles, not varicella. They appear as small blue-white lesions on the buccal mucosa before the measles rash develops.
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