Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A. Use liquids to clear food from the client's mouth.
Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.
B. Tilt the client's head backwards to facilitate swallowing.
Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.
C. Add a thickening agent to liquids.
Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.
D. Place the client in a semi-Fowler's position.
Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nutrition 2019 Nexy Updated 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Using liquids to clear food from the client's mouth is not a safe intervention for dysphagia. Liquids can easily enter the airway and cause aspiration, which is the inhalation of food or fluids into the lungs. Aspiration can lead to pneumonia, respiratory distress, and death.
Choice B reason: Tilting the client's head backwards to facilitate swallowing is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it opens the airway and allows food or fluids to flow into it.
Choice C reason: Adding a thickening agent to liquids is a safe and effective intervention for dysphagia. Thickened liquids are easier to swallow and control, as they move more slowly through the mouth and throat. They also reduce the risk of aspiration, as they are less likely to enter the airway.
Choice D reason: Placing the client in a semi-Fowler's position is not a safe intervention for dysphagia. This position can also increase the risk of aspiration, as it lowers the head and neck and reduces the closure of the airway. A better position for dysphagia is upright or high-Fowler's, which elevates the head and neck and enhances the closure of the airway.
Similar Questions
A nurse is teaching a parent about appropriate snack choices for her 9-month-old infant. Which of the following food choices should the nurse recommend?
A. Skim milk
Skim milk is not an appropriate snack choice for a 9-month-old infant. Infants under 12 months of age should not consume cow's milk, as it can cause iron deficiency, gastrointestinal bleeding, and allergic reactions. Infants should be breastfed or formula-fed until they are 12 months old.
B. Unsalted popcorn
Unsalted popcorn is not an appropriate snack choice for a 9-month-old infant. Popcorn is a choking hazard for infants, as it can easily get stuck in their throat or lungs. Infants should not be given any hard, round, or sticky foods that can cause choking.
C. Raw carrots
Raw carrots are not an appropriate snack choice for a 9-month-old infant. Raw carrots are also a choking hazard for infants, as they are hard and difficult to chew and swallow. Infants should be given soft, cooked, or pureed vegetables that can be easily mashed with their gums.
D. Graham crackers
Graham crackers are an appropriate snack choice for a 9-month-old infant. Graham crackers are soft, easy to chew and swallow, and provide carbohydrates and energy. They can also help infants practice their self-feeding skills and finger coordination.
Full Explanation
Choice A reason: Skim milk is not an appropriate snack choice for a 9-month-old infant. Infants under 12 months of age should not consume cow's milk, as it can cause iron deficiency, gastrointestinal bleeding, and allergic reactions. Infants should be breastfed or formula-fed until they are 12 months old.
Choice B reason: Unsalted popcorn is not an appropriate snack choice for a 9-month-old infant. Popcorn is a choking hazard for infants, as it can easily get stuck in their throat or lungs. Infants should not be given any hard, round, or sticky foods that can cause choking.
Choice C reason: Raw carrots are not an appropriate snack choice for a 9-month-old infant. Raw carrots are also a choking hazard for infants, as they are hard and difficult to chew and swallow. Infants should be given soft, cooked, or pureed vegetables that can be easily mashed with their gums.
Choice D reason: Graham crackers are an appropriate snack choice for a 9-month-old infant. Graham crackers are soft, easy to chew and swallow, and provide carbohydrates and energy. They can also help infants practice their self-feeding skills and finger coordination.
A nurse is providing teaching about the Dietary Approaches to Stop Hypertension (DASH) diet to a client who has hypertension. Which of the following instructions should the nurse include?
A. Consume ten percent of total calories from saturated fat.
Consume ten percent of total calories from saturated fat is not a correct instruction for the DASH diet. The DASH diet recommends limiting saturated fat intake to less than six percent of total calories, as saturated fat can raise blood cholesterol and increase the risk of heart disease.
B. Consume foods that are high in calcium.
Consume foods that are high in calcium is a correct instruction for the DASH diet. The DASH diet emphasizes eating foods that are rich in calcium, such as low-fat dairy products, leafy green vegetables, and fortified cereals. Calcium helps regulate blood pressure and prevent osteoporosis.
C. Increase intake of refined carbohydrates.
Increase intake of refined carbohydrates is not a correct instruction for the DASH diet. The DASH diet advises reducing intake of refined carbohydrates, such as white bread, white rice, and sweets. Refined carbohydrates can increase blood sugar and insulin levels and contribute to obesity and diabetes.
D. Limit sodium intake to 3,200 milligrams per day.
Limit sodium intake to 3,200 milligrams per day is not a correct instruction for the DASH diet. The DASH diet recommends limiting sodium intake to less than 2,300 milligrams per day, or even lower to 1,500 milligrams per day for some people. Sodium can increase blood pressure and fluid retention and damage the kidneys and blood vessels.
Full Explanation
Choice A reason: Consume ten percent of total calories from saturated fat is not a correct instruction for the DASH diet. The DASH diet recommends limiting saturated fat intake to less than six percent of total calories, as saturated fat can raise blood cholesterol and increase the risk of heart disease.
Choice B reason: Consume foods that are high in calcium is a correct instruction for the DASH diet. The DASH diet emphasizes eating foods that are rich in calcium, such as low-fat dairy products, leafy green vegetables, and fortified cereals. Calcium helps regulate blood pressure and prevent osteoporosis.
Choice C reason: Increase intake of refined carbohydrates is not a correct instruction for the DASH diet. The DASH diet advises reducing intake of refined carbohydrates, such as white bread, white rice, and sweets. Refined carbohydrates can increase blood sugar and insulin levels and contribute to obesity and diabetes.
Choice D reason: Limit sodium intake to 3,200 milligrams per day is not a correct instruction for the DASH diet. The DASH diet recommends limiting sodium intake to less than 2,300 milligrams per day, or even lower to 1,500 milligrams per day for some people. Sodium can increase blood pressure and fluid retention and damage the kidneys and blood vessels.
A nurse is providing dietary teaching to a client newly diagnosed with celiac disease. Which of the following information should the nurse include in the teaching?
A. Dietary restrictions will eventually allow the intake of gluten to resume.
Dietary restrictions will not eventually allow the intake of gluten to resume. Gluten is a protein found in wheat, barley, rye, and some oats. It causes damage to the small intestine in people with celiac disease. The only treatment for celiac disease is a lifelong gluten-free diet.
B. This condition may cause secondary lactose intolerance.
This condition may cause secondary lactose intolerance. Lactose is a sugar found in milk and dairy products. It is broken down by an enzyme called lactase in the small intestine. People with celiac disease may have reduced levels of lactase due to the damage to the small intestine caused by gluten. This can lead to lactose intolerance, which is the inability to digest lactose properly. Symptoms of lactose intolerance include bloating, gas, diarrhea, and abdominal pain after consuming dairy products.
C. Nutritional therapy for this condition includes limiting proteins and calories.
Nutritional therapy for this condition does not include limiting proteins and calories. People with celiac disease need adequate amounts of proteins and calories to maintain their health and prevent malnutrition. They also need to ensure that they get enough vitamins, minerals, and fiber from gluten-free sources.
D. A normal diet can resume after a period of remission.
A normal diet cannot resume after a period of remission. Celiac disease is a chronic autoimmune disorder that does not have a cure. Even if the symptoms improve or disappear, the damage to the small intestine can still occur if gluten is consumed. Therefore, a strict gluten-free diet must be followed for life.
Full Explanation
Choice A reason: Dietary restrictions will not eventually allow the intake of gluten to resume. Gluten is a protein found in wheat, barley, rye, and some oats. It causes damage to the small intestine in people with celiac disease. The only treatment for celiac disease is a lifelong gluten-free diet.
Choice B reason: This condition may cause secondary lactose intolerance. Lactose is a sugar found in milk and dairy products. It is broken down by an enzyme called lactase in the small intestine. People with celiac disease may have reduced levels of lactase due to the damage to the small intestine caused by gluten. This can lead to lactose intolerance, which is the inability to digest lactose properly. Symptoms of lactose intolerance include bloating, gas, diarrhea, and abdominal pain after consuming dairy products.
Choice C reason: Nutritional therapy for this condition does not include limiting proteins and calories. People with celiac disease need adequate amounts of proteins and calories to maintain their health and prevent malnutrition. They also need to ensure that they get enough vitamins, minerals, and fiber from gluten-free sources.
Choice D reason: A normal diet cannot resume after a period of remission. Celiac disease is a chronic autoimmune disorder that does not have a cure. Even if the symptoms improve or disappear, the damage to the small intestine can still occur if gluten is consumed. Therefore, a strict gluten-free diet must be followed for life.