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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Inflating the blood pressure cuff 30 mmHg above the point where the radial pulse disappears is correct. This method, known as the palpatory method, prevents auscultatory gap errors and ensures an accurate blood pressure reading.
B. Assisting the patient to a standing position for five to ten minutes is incorrect unless assessing for orthostatic hypotension. For routine blood pressure measurements, the client should be seated and at rest for at least five minutes.
C. Palpating the radial artery and placing the stethoscope lightly over this area is incorrect because blood pressure is auscultated over the brachial artery, not the radial artery.
D. Measuring the blood pressure cuff to encircle 60% of the client’s arm is incorrect. The correct guideline is that the cuff bladder should encircle at least 80% of the arm circumference, not 60%.
Correct Answer is D
Explanation
A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.
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