Exhibits
A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching?
Client Statements
"I will look up at the ceiling when I swallow."
"I will have to stop watching television while I eat."
"My food will have to be the consistency of pudding."
"I can have cream soups on this diet."
"I shouldn't drink liquids while I have food in my mouth."
"I won't be able to eat nuts anymore."
Correct Answer : B,C,E,F
A. "I will look up at the ceiling when I swallow.". The recommended position for swallowing is typically sitting upright with the chin slightly tucked.
B. "I will have to stop watching television while I eat." This indicates an understanding of the importance of focusing on eating and avoiding distractions.
C. "My food will have to be the consistency of pudding." This indicates understanding of the Level 3 dysphagia diet, which requires foods to be moist and easily swallowed.
D. "I can have cream soups on this diet." While cream soups might seem like a good option, they can be too thick for a Level 3 dysphagia diet. The consistency should be more like a thin purée.
E. "I shouldn't drink liquids while I have food in my mouth." This demonstrates understanding of the importance of avoiding choking hazards.
F. "I won't be able to eat nuts anymore." This indicates understanding of the restrictions on hard, crunchy foods on a Level 3 dysphagia diet.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The client opens his eyes in response to voice, which scores 3 on the eye-opening part of the GCS.
Since the client does not understand questions, this would likely score 1 for verbal response, indicating incomprehensible sounds.
The motor response of bringing an arm up to a trapezius squeeze is localizing pain, which would score 5.
Therefore, the nurse would document the client's GCS score as E3V1M5, which totals to 9 out of a possible 15 points.
Correct Answer is C
Explanation
A. Restraining the child's arms during a seizure is not recommended. Trying to hold or restrain a child’s movements can lead to injury for both the child and the caregiver. During a seizure, it is more important to ensure the child is in a safe environment and avoid any actions that might exacerbate the situation or cause harm.
B. Using a padded tongue blade is an outdated practice and is not recommended. This method was once thought to prevent the child from biting their tongue or injuring their mouth, but it can actually lead to broken teeth, injuries to the mouth, or cause airway obstruction. Instead, focusing on ensuring the child's safety and protecting their airway is more appropriate.
C. Positioning the child laterally (on their side) is an appropriate and recommended action during a seizure. This position helps keep the airway open and allows any fluids, such as saliva, to drain out of the mouth, which helps prevent aspiration and choking. This position is especially important if the child is at risk for vomiting or if the seizure lasts for a prolonged period.
D. Attempting to stop the seizure is not possible and is not recommended. Seizures typically resolve on their own, and trying to intervene actively can cause harm. Instead, focus on protecting the child from injury, monitoring the duration of the seizure, and providing support once the seizure is over.
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