A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

Speech therapy referral

Dietitian consult

Oral suction at the bedside

Clear liquids

Answer and Explanation

The Correct Answer is D

A. Speech therapy referral: A speech therapy referral is appropriate for a client with dysphagia following a stroke. Speech therapists can assess the severity of swallowing difficulties and provide strategies to improve swallowing function. This is standard care.

B. Dietitian consult: A dietitian consult is essential to ensure proper nutritional intake and modify the client's diet for safe swallowing. A dietitian can help adjust the texture of foods and recommend alternatives to reduce the risk of aspiration.

C. Oral suction at the bedside: Oral suctioning is a precautionary measure for clients with dysphagia to clear any potential obstructions from the airway. It’s essential to have suction equipment available at the bedside in case of choking or aspiration.

D. Clear liquids: Clear liquids are not recommended for clients with dysphagia because they pose a higher risk for aspiration. Clear liquids can be difficult for individuals with swallowing difficulties to control and may lead to choking or aspiration pneumonia.

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Correct Answer is D

Explanation

A. Muscle flaccidity: Hypocalcemia typically causes muscle twitching or spasms, not flaccidity. Muscle flaccidity is more often associated with conditions like hyperkalemia or electrolyte imbalances affecting muscle tone in different ways.

B. Lethargy: Lethargy can occur in various conditions, but it is not a hallmark of hypocalcemia. Instead, hypocalcemia usually causes symptoms like irritability, confusion, and muscle cramps rather than general lethargy.

C. Constipation: Constipation is more commonly associated with hypercalcemia, not hypocalcemia. Low calcium levels tend to cause neuromuscular and cardiac symptoms rather than gastrointestinal issues like constipation.

D. Positive Chvostek's sign: A positive Chvostek's sign, which is a twitching of the facial muscles when tapping the facial nerve, is a classic sign of hypocalcemia. It indicates increased neuromuscular excitability, which is characteristic of low calcium levels.

A. Depression B. Bargaining C. Denial D. Acceptance

Correct Answer is D

Explanation

A. Depression: Depression typically involves feelings of sadness, despair, and withdrawal. The client's statement about wanting comfort, rather than prolonged sadness, reflects acceptance, not depression.

B. Bargaining: Bargaining is when individuals try to make deals to reverse their situation, often asking for more time. The client’s statement reflects a decision to stop treatment, not bargaining for more time.

C. Denial: Denial involves refusing to acknowledge the reality of the situation. The client’s statement shows recognition of their condition and prioritizing comfort, which shows acceptance rather than denial.

D. Acceptance: In the acceptance stage, individuals come to terms with their diagnosis and focus on achieving peace. The client’s request for comfort care is consistent with acceptance, where they focus on making the most of their time.

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A nurse is reviewing the prescriptions for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify?

Nursing Test Bank

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