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
The correct answer is: a. Development of subcutaneous emphysema
Choice A: Development of subcutaneous emphysema
Reason: Subcutaneous emphysema occurs when air gets trapped under the skin, often due to a leak from the lung or chest tube. This can indicate a serious complication such as a pneumothorax or a malfunctioning chest tube, requiring immediate medical intervention. The presence of subcutaneous emphysema can lead to discomfort, respiratory distress, and further complications if not addressed promptly.
Choice B: Chest tube eyelets not visible
Reason: The eyelets of a chest tube are small holes at the end of the tube that allow air and fluid to drain from the pleural space. These eyelets are typically covered by a dressing and may not be visible. This is not necessarily a cause for concern unless there are other signs of malfunction or complications.
Choice C: Continuous bubbling in the suction control chamber
Reason: Continuous bubbling in the suction control chamber is expected and indicates that the suction is functioning properly. It does not indicate a problem unless the bubbling is in the water seal chamber, which would suggest an air leak.
Choice D: Presence of tidal fluctuation in the water seal chamber
Reason: Tidal fluctuation, or tidaling, in the water seal chamber is a normal finding. It indicates that the chest tube is patent and functioning correctly, as the water level rises with inhalation and falls with exhalation. The absence of tidaling could indicate a blockage or that the lung has fully re-expanded.
Correct Answer is D
Explanation
Choice A reason: Administer low flow oxygen continuously via nasal cannula. This intervention is not appropriate because it does not provide enough oxygen to meet the needs of a client with ARDS. A client with ARDS requires high flow oxygen delivered by a mechanical ventilator or a noninvasive positive pressure device.
Choice B reason: Encourage oral intake of at least 3,000 mL of fluids per day. This intervention is not appropriate because it can worsen the pulmonary edema and hypoxemia that occur in ARDS. A client with ARDS requires fluid restriction and diuretics to reduce the fluid accumulation in the lungs.
Choice C reason: Offer high protein and high carbohydrate foods frequently. This intervention is appropriate because it provides adequate nutrition and energy to support the client's metabolic needs and prevent muscle wasting. A client with ARDS has increased caloric and protein requirements due to the increased work of breathing and the inflammatory response.
Choice D reason: Place in a prone position. This intervention is effective because it improves oxygenation and ventilation by increasing lung volume and reducing the effects of gravity on the lungs.
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