The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Delegate the feeding to the nursing student.

Place the food on the affected side of the mouth.

Keep the television off while feeding the client.

Ensure the client's head of the bed is less than 30 degrees.

Answer and Explanation

The Correct Answer is C

A.   While the nursing student may assist with feeding, the nurse should always assess the client's swallowing ability and provide direct supervision to ensure the client's safety.
B.   Placing food on the affected side of the mouth can increase the risk of aspiration. The food should be placed on the unaffected side of the mouth.
C.   Distractions can impair the client's ability to focus on swallowing and increase the risk of aspiration. A quiet environment can help the client concentrate on eating.
D.   The head of the bed should be elevated to at least 30 degrees during and after feeding to reduce the risk of aspiration.

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Correct Answer is C

Explanation

A. This is not an appropriate action as it can increase pressure on the bladder and worsen the spasms.
B. While warming the irrigation solution can help to prevent discomfort, it is not the most effective way to address the bladder spasms.
C. Belladonna and opium suppositories are commonly used to relieve bladder spasms. They work by relaxing the muscles in the bladder and reducing pain. In a client who has undergone TURBT and is experiencing continuous bladder irrigation, these suppositories can be an effective way to manage discomfort.
D. Meperidine is a narcotic pain reliever that can be used to manage pain after surgery. However, it is not specifically indicated for bladder spasms and may not be the most appropriate medication in this case.

A. Shortness of breath, especially when lying flat B. Pain/swelling of the lymph nodes C. Low grade fevers of unknown etiology D. Drenching night sweats

Correct Answer is A

Explanation

A. A mass in the mediastinum can compress the trachea or major blood vessels, leading to shortness of breath, particularly when the patient is in a supine position (lying flat). This symptom is indicative of significant obstruction or compression, making it a key sign.
B. While lymphadenopathy (swelling of lymph nodes) is a hallmark of Hodgkin's Lymphoma, it does not specifically indicate the presence of a mediastinal mass. Lymph nodes can swell throughout the body, including cervical, axillary, and inguinal regions, but this symptom is more general and not exclusive to mediastinal involvement.
C. Low-grade fevers can occur in Hodgkin's Lymphoma due to systemic effects of the cancer, such as cytokine release. However, this symptom is nonspecific and does not directly indicate a mediastinal mass. It is more indicative of the body's response to cancer rather than localized effects.
D. Drenching night sweats are another common systemic symptom associated with Hodgkin's Lymphoma. Like low-grade fevers, night sweats are part of the B symptoms that can occur with lymphoma but are not specifically indicative of a mediastinal mass.

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The nurse is caring for the client who has dysphagia following an ischemic stroke. The client is ordered a pureed diet starting today. Which intervention would be appropriate for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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