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

Answer and Explanation

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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Correct Answer is D

Explanation

A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.

B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.

C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.

D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.

A. Leave the client alone during a new experience. B. Give support in nonverbal ways. C. Be available and attentive to the client's requirements. D. Give detailed explanations and do not repeat them frequently.

Correct Answer is C

Explanation

A. Leave the client alone during a new experience. Leaving an anxious client alone during a new experience may increase their anxiety and hinder the development of trust. Clients need support and reassurance during unfamiliar situations.

B. Give support in nonverbal ways. Nonverbal support, such as a calm presence or gentle touch, can be comforting and help build trust without overwhelming the client with too much verbal communication.

C. Be available and attentive to the client's requirements. Being available and attentive shows the client that the nurse is reliable and responsive to their needs, which helps build trust in the therapeutic relationship.

D. Give detailed explanations and do not repeat them frequently. While providing detailed explanations is important, failing to repeat them as needed could leave the client feeling unsupported or confused, especially if they need reassurance.

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The nurse is caring for a client with dysphagia. Which intervention would be contraindicated while caring for this client?

Nursing Test Bank

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