Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who has dysphagia and left-sided weakness following a stroke. Which of the following actions should the nurse take?
A. Instruct the client to tilt her head back when she swallows.
Instruct the client to tilt her head back when she swallows.Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.
B. Place food on the left side of the client’s mouth.
Place food on the left side of the client’s mouth.Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.
C. Add thickener to fluids.
Add thickener to fluids. This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.
D. Serve food at room temperature.
Serve food at room temperature.While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.
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Full Explanation
A. Instruct the client to tilt her head back when she swallows.
Tipping the head back during swallowing is not recommended, especially for individuals with dysphagia. It can increase the risk of aspiration, as it may interfere with the normal swallowing mechanism. The head should be kept in a neutral position during swallowing.
B. Place food on the left side of the client’s mouth.
Placing food on the side with weakness may lead to difficulty in chewing and increased risk of aspiration. The placement of food should be based on the individual's ability and preference, and it's important to consider the safety of swallowing.
C. Add thickener to fluids.
This is the correct choice. Adding thickener to fluids can help modify their consistency, making them easier to swallow and reducing the risk of aspiration. The appropriate thickness should be determined based on the individual's ability to swallow safely.
D. Serve food at room temperature.
While serving food at room temperature may be a preference for some individuals, it is not specifically addressing the safety concerns related to dysphagia and left-sided weakness. The focus should be on modifying food textures and consistencies to ensure safe swallowing.
Similar Questions
A nurse is helping an older adult client ambulate in the hallway for the first time since admission. The client has brought a standard walker from home. To ensure proper use of the walker and the safety of the client, which of the following actions should the nurse take?
A. Check that the client lifts the walker and then places it down in front of her.
Check that the client lifts the walker and then places it down in front of her.To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.
B. Walk in front of the client to guide her in moving the walker.
Walk in front of the client to guide her in moving the walker.The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.
C. Have the client move one leg forward with the walker.
Have the client move one leg forward with the walker. The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.
D. Make sure that the upper bar of the walker is level with the client’s waist.
Make sure that the upper bar of the walker is level with the client’s waist.The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.
Full Explanation
A. Check that the client lifts the walker and then places it down in front of her.
To ensure proper use of a standard walker and the safety of the client, the nurse should check that the client lifts the walker and then places it down in front of her. This sequence of lifting and moving the walker forward provides stability and support during ambulation.
B. Walk in front of the client to guide her in moving the walker.
The nurse should walk beside or slightly behind the client to provide support and supervision. Walking in front may hinder the client's ability to maneuver the walker.
C. Have the client move one leg forward with the walker.
The proper technique is for the client to move the walker forward and then step into it with the affected leg. Moving one leg forward with the walker may compromise stability.
D. Make sure that the upper bar of the walker is level with the client’s waist.
The correct height of the walker is essential for proper use. The walker should be adjusted to the client's height, with the top bar at the level of the client's wrists when their arms are at their sides, not at the waist.
A nurse is assisting with meal planning for a client who has hypothyroidism. The nurse should reinforce with the client that she should increase her daily intake of which of the following nutrients?
A. Fiber
FiberFor a client with hypothyroidism, the nurse should reinforce the importance of increasing daily intake of fiber. Hypothyroidism can sometimes lead to constipation, and a diet rich in fiber can help alleviate this symptom.
B. Monounsaturated fats
Monounsaturated fatsWhile monounsaturated fats are considered heart-healthy and can be included in a balanced diet, they are not particularly emphasized or increased for clients with hypothyroidism.
C. Protein
Protein Adequate protein intake is important for overall health, but there is no specific recommendation to increase protein intake solely because of hypothyroidism.
D. Polyunsaturated fats
Polyunsaturated fatsSimilar to monounsaturated fats, polyunsaturated fats are part of a healthy diet, but there is no specific emphasis on increasing their intake for clients with hypothyroidism.
Full Explanation
A. Fiber
For a client with hypothyroidism, the nurse should reinforce the importance of increasing daily intake of fiber. Hypothyroidism can sometimes lead to constipation, and a diet rich in fiber can help alleviate this symptom.
B. Monounsaturated fats
While monounsaturated fats are considered heart-healthy and can be included in a balanced diet, they are not particularly emphasized or increased for clients with hypothyroidism.
C. Protein
Adequate protein intake is important for overall health, but there is no specific recommendation to increase protein intake solely because of hypothyroidism.
D. Polyunsaturated fats
Similar to monounsaturated fats, polyunsaturated fats are part of a healthy diet, but there is no specific emphasis on increasing their intake for clients with hypothyroidism.
A nurse is talking about joint protection strategies with an older adult client who has osteoarthritis. Which of the following recommendations should the nurse reinforce?
A. Jog or run three times a week.
Jog or run three times a week.This option is not a recommended joint protection strategy for osteoarthritis. High-impact activities like jogging or running can potentially exacerbate symptoms and increase stress on weight-bearing joints.
B. Choose soft, pillowed chairs for sitting.
Choose soft, pillowed chairs for sitting.While comfortable seating is important for general comfort, it is not a specific joint protection strategy for osteoarthritis. The emphasis for osteoarthritis management is on maintaining joint function through appropriate exercise and weight management.
C. Maintain the recommended body weight.
Maintain the recommended body weight. This is the correct choice. Maintaining the recommended body weight is a crucial joint protection strategy for individuals with osteoarthritis, as excess body weight can contribute to increased stress on weight-bearing joints, leading to worsened symptoms.
D. Reduce the amount of purine in the diet.
Reduce the amount of purine in the diet.This recommendation is more relevant for conditions like gout, which is characterized by the deposition of uric acid crystals in joints. It is not a specific joint protection strategy for osteoarthritis.
Full Explanation
A. Jog or run three times a week.
This option is not a recommended joint protection strategy for osteoarthritis. High-impact activities like jogging or running can potentially exacerbate symptoms and increase stress on weight-bearing joints.
B. Choose soft, pillowed chairs for sitting.
While comfortable seating is important for general comfort, it is not a specific joint protection strategy for osteoarthritis. The emphasis for osteoarthritis management is on maintaining joint function through appropriate exercise and weight management.
C. Maintain the recommended body weight.
This is the correct choice. Maintaining the recommended body weight is a crucial joint protection strategy for individuals with osteoarthritis, as excess body weight can contribute to increased stress on weight-bearing joints, leading to worsened symptoms.
D. Reduce the amount of purine in the diet.
This recommendation is more relevant for conditions like gout, which is characterized by the deposition of uric acid crystals in joints. It is not a specific joint protection strategy for osteoarthritis.