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 A

Explanation

A. drowsiness: Drowsiness is a common side effect of many antianxiety medications, especially benzodiazepines. This can impair the client’s ability to safely drive or perform tasks requiring alertness, making this the most appropriate choice.

B. confusion: While confusion can occur with some antianxiety drugs, it is less common than drowsiness and typically occurs at higher doses or with prolonged use.

C. behavior changes: Behavior changes can occur but are less common and are not the primary reason for caution with activities requiring mental alertness.

D. sleep disorders: Sleep disorders are not a typical side effect of antianxiety medications; in fact, these drugs are often used to treat sleep disturbances.

A. Generalized pain B. Alteration in level of consciousness (LOC) C. Tonic-clonic seizures D. Shortness of breath

Correct Answer is B

Explanation

A. Generalized pain: Generalized pain is not a typical early sign of deterioration following a hemorrhagic stroke.

B. Alteration in level of consciousness (LOC): An alteration in LOC is often the earliest and most sensitive sign of neurological deterioration in clients who have had a hemorrhagic stroke. This can indicate increased intracranial pressure or further bleeding.

C. Tonic-clonic seizures: While seizures can occur after a stroke, they are not typically the earliest sign of deterioration. Changes in LOC usually precede seizure activity.

D. Shortness of breath: Shortness of breath may indicate respiratory issues but is not directly related to early neurological deterioration following a stroke.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

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