The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?
Assisting the client with meals
Placing food on the affected side of the mouth
Testing the gag reflex before offering food or fluids
Allowing ample time to eat
The Correct Answer is B
A. Assisting the client with meals: Assisting the client with meals is appropriate, as clients with dysphagia may need help to ensure safe swallowing and to avoid choking or aspiration.
B. Placing food on the affected side of the mouth: This is contraindicated because placing food on the affected side could increase the risk of choking or aspiration, as the client may not have adequate control over swallowing on the affected side.
C. Testing the gag reflex before offering food or fluids: Testing the gag reflex is appropriate for ensuring that the client has an intact protective reflex before eating or drinking, reducing the risk of aspiration.
D. Allowing ample time to eat: Allowing the client ample time to eat is important to prevent rushing, which could increase the risk of choking or aspiration. It ensures that the client can safely swallow their food.
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Related Questions
Correct Answer is D
Explanation
A. Hypokalemia or hyponatremia: While electrolyte imbalances are important, they are not the most immediate threat in the context of a heroin overdose.
B. Acute gastrointestinal bleed: An acute gastrointestinal bleed is not a primary concern with heroin overdose. It is not the most acute threat in this scenario.
C. Increased intracranial pressure: Increased intracranial pressure is not directly related to heroin overdose. The most pressing issue is related to the effects of the overdose.
D. Respiratory depression: Heroin overdose commonly leads to respiratory depression, which is the most immediate and life-threatening condition. Addressing respiratory depression is crucial for patient survival.
Correct Answer is B
Explanation
A. "Are you feeling worse since taking the medication?" This is an important safety question to ask, as it helps to assess whether the client’s condition has worsened since starting the medication. However, it is not the first priority when evaluating the efficacy of a newly prescribed antidepressant.
B. "How long have you been taking the medication?" This is the most important question to ask first because the effectiveness of imipramine, a tricyclic antidepressant, can take several weeks to become apparent. If the client has not been taking the medication for an adequate period, the drug may simply not have had enough time to work yet.
C. "What time of day are you taking the medication?" While the timing of the medication can affect side effects, it is less critical than knowing how long the client has been on the medication when assessing its effectiveness.
D. "What dosage of medication are you taking?" This is an important follow-up question but not the first priority. The duration of treatment is more critical to assess before considering dosage adjustments.
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