A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client’s partner should indicate to the nurse that the teaching was effective?
My partner should place their food on the weaker side of their mouth when eating.
My partner should tilt their head forward when swallowing.
My partner should cough while swallowing food.
My partner should sit at a 30° angle while eating their meals.
The Correct Answer is B
Choice A reason: Placing food on the weaker side of the mouth when eating is not an effective strategy for a client who has dysphagia. This can increase the risk of choking or aspiration, as the food may not be chewed properly or may slip into the airway. The client should place food on the stronger side of the mouth and use the tongue to move it to the back of the throat for swallowing.
Choice B reason: Tilting the head forward when swallowing is an effective technique for a client who has dysphagia. This can help to close off the airway and prevent food or liquid from entering the lungs. The client should also tuck the chin down to the chest and swallow hard.
Choice C reason: Coughing while swallowing food is not a desirable outcome for a client who has dysphagia. This can indicate that the food is going into the wrong pipe and causing irritation or obstruction. The client should try to avoid coughing while swallowing and clear the throat after each bite or sip.
Choice D reason: Sitting at a 30° angle while eating meals is not a sufficient position for a client who has dysphagia. This can still allow food or liquid to flow back into the throat and cause choking or aspiration. The client should sit upright at a 90° angle and remain in that position for at least 30 minutes after eating.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Ask the client to read a Snellen chart. This method is used to assess cranial nerve II, which is the optic nerve. The optic nerve is responsible for vision and visual acuity. A Snellen chart is a tool that displays letters of different sizes and measures how well the client can see them from a distance of 20 feet.
Choice B reason: Ask the client to clench his teeth. This method is not used to assess cranial nerve II, but cranial nerve V, which is the trigeminal nerve. The trigeminal nerve is responsible for sensation and motor function of the face, mouth, and jaw. Clenching the teeth tests the strength and symmetry of the masseter and temporalis muscles, which are innervated by the trigeminal nerve.
Choice C reason: Listen to the client’s speech. This method is not used to assess cranial nerve II, but cranial nerves IX, X, and XII, which are the glossopharyngeal, vagus, and hypoglossal nerves. These nerves are responsible for speech production and swallowing. Listening to the client’s speech tests the quality, clarity, and articulation of the voice, as well as the movement and coordination of the tongue and palate.
Choice D reason: Ask the client to identify scented aromas. This method is not used to assess cranial nerve II, but cranial nerve I, which is the olfactory nerve. The olfactory nerve is responsible for smell and olfaction. Asking the client to identify scented aromas tests the ability to detect and recognize different odors.
Correct Answer is B
Explanation
Choice A reason: Positioning the head of the client’s bed in the flat position is not a good way to reduce the risk of ventilator associated pneumonia. This position can increase the risk of aspiration of oral secretions or gastric contents into the lungs, which can cause infection. The nurse should elevate the head of the bed to 30 to 45 degrees to prevent aspiration and promote drainage of secretions.
Choice B reason: Brushing the client’s teeth with a suction toothbrush every 12 hr is an effective way to reduce the risk of ventilator associated pneumonia. Oral hygiene can reduce the number of bacteria in the mouth and prevent the formation of dental plaque, which can harbor pathogens that can cause pneumonia. The nurse should use a suction toothbrush to remove debris and secretions from the mouth and prevent them from entering the lungs.
Choice C reason: Providing humidity by maintaining moisture within the ventilator tubing is not a helpful way to reduce the risk of ventilator associated pneumonia. Humidity can increase the growth of bacteria and fungi in the ventilator circuit, which can contaminate the air delivered to the lungs. The nurse should change the ventilator tubing and filters regularly and use sterile water to fill the humidifier.
Choice D reason: Turning the client every 4 hr is not a sufficient way to reduce the risk of ventilator associated pneumonia. Turning can help prevent pressure ulcers and improve blood circulation, but it does not prevent the accumulation of secretions in the lungs, which can cause infection. The nurse should use chest physiotherapy, suctioning, and coughing techniques to mobilize and clear secretions from the airways.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today