A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Ask the client to tilt their head back when swallowing.

Have the client sit upright for 1 hr following meals.

Administer liquids to the client using a syringe.

Allow the client to rest for 10 min prior to eating.

Answer and Explanation

The Correct Answer is B

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

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Correct Answer is C

Explanation

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

A. Dryness B. Edema C. Erythema D. A distended vein

Correct Answer is B

Explanation

A. Dryness – Infiltration leads to swelling and fluid accumulation, not dryness.

B. Edema – Infiltration occurs when IV fluids leak into surrounding tissue, causing swelling (edema).

C. Erythema – While redness (erythema) can indicate phlebitis, it is not a primary sign of infiltration.

D. A distended vein – A distended vein is more likely seen with fluid overload or thrombosis, not infiltration.

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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