The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

Drink fluids before and after, but not during, meals

Sit with the head of the bed at a 45-degree angle during meals

Thoroughly chew small amounts of food with each mouthful

Be aware of the possibility of temporomandibular joint pain

Answer and Explanation

The Correct Answer is C

A. Drinking fluids before and after meals but not during meals is incorrect. Clients with dysphagia may require thickened liquids and should sip fluids as needed to facilitate swallowing.
B. Sitting with the head of the bed at a 45-degree angle is incorrect. Clients with dysphagia should be positioned at a 90-degree angle (fully upright) during meals to reduce the risk of aspiration.
C. Thoroughly chewing small amounts of food with each mouthful is correct. Clients with dysphagia should eat slowly, take small bites, and chew food thoroughly to prevent choking and aspiration.
D. Temporomandibular joint pain is not a common issue associated with dysphagia following a stroke. The primary concern is the risk of aspiration.

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Correct Answer is A

Explanation

A. The client's ability to change position is correct. The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Limited mobility increases the risk for pressure injuries.
B. A history of integumentary disorders is not part of the Braden Scale assessment. The scale focuses on current risk factors rather than past dermatologic conditions.
C. Skin pigmentation is not a factor in pressure ulcer risk assessment. However, in clients with darker skin, early signs of pressure injuries may be harder to detect due to lack of visible blanching.
D. Medications are not directly included in the Braden Scale. While some medications (e.g., steroids) can increase pressure injury risk, the Braden Scale does not specifically assess them.

A. Collect client data in order to make a professional clinical judgment of the client's overall level of functioning. B. Provides information about chronic diseases and medications to identify how a present illness is impacting the client. C. Compile data during a step-by-step physical examination. D. Focuses on the client's physiologic status in order to implement provider decisions.

Correct Answer is A

Explanation

A. Collecting client data to make a professional clinical judgment of the client's overall level of functioning is correct because a nursing health assessment evaluates the client holistically, including physical, psychological, and social aspects of health.
B. While a nursing assessment includes chronic diseases and medications, it is broader than just identifying how a present illness is impacting the client.
C. A step-by-step physical examination is one component of the assessment, but the primary purpose is to make a clinical judgment.
D. Nursing assessments go beyond just implementing provider decisions and focus on patient-centered care.

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The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

Correct Answer is A

Explanation

What is the primary purpose of a nursing health assessment?

Correct Answer is A

Explanation

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The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

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