A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

Stroke under the chin in a downward motion.

Keep pulse oximeter ready at all times.

Avoid rushing the client or force feeding her.

facial weakness is present, place food on the impaired side of the mouth.

Alternate solid and liquid boluses

Have the client sit at 90 degrees during all of oral intake

Answer and Explanation

Correct Answer : C,D,E,F

A. Stroke under the chin in a downward motion.
Explanation: Stroking under the chin in a downward motion is not considered a standard technique for managing dysphagia. It's important to focus on strategies that promote safe swallowing and prevent aspiration.

B. Keep pulse oximeter ready at all times.
Explanation: While monitoring oxygen saturation is important in certain situations, having a pulse oximeter ready at all times may not be a routine instruction for feeding a client with dysphagia. Monitoring for signs of distress and ensuring a safe feeding environment are key aspects of care.

C. Avoid rushing the client or force feeding her.
Explanation: Rushing or force-feeding a client with dysphagia can increase the risk of aspiration. It's important to allow the client to eat at their own pace and take adequate time to chew and swallow safely.

D. If facial weakness is present, place food on the impaired side of the mouth.
Explanation: Placing food on the impaired side of the mouth can help compensate for facial weakness and promote more effective chewing and swallowing.

E. Alternate solid and liquid boluses.
Explanation: Alternating solid and liquid boluses can help with the overall coordination of the swallowing process. It can also facilitate the movement of food and liquids through the digestive tract.

F. Have the client sit at 90 degrees during all of oral intake.
Explanation: Ensuring that the client sits at a 90-degree angle during oral intake helps promote an upright position that aids in swallowing and reduces the risk of aspiration.

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Correct Answer is B

Explanation

A. While using an assistive device can be helpful, it's more of a compensatory measure and does not directly address the improvement of balance. It's important to focus on interventions that enhance balance rather than relying solely on external devices.

B. Providing information on group exercises for balance training is a suitable intervention.

Group exercises specifically targeting balance can offer a supportive and structured environment for the older adult.

Balance training in a group setting can provide social interaction, motivation, and a sense of community, which can contribute to adherence and engagement in the program.

C. Enrolling in a general exercise program for 8 weeks may not be as targeted or tailored to the specific needs of someone recovering from balance issues. Specific balance training exercises would likely be more beneficial.

D. Learning how to exercise the core group of muscles is important for overall strength and stability, but it may not be sufficient in addressing balance issues comprehensively. Balance-specific exercises should also be included.

A. "Side rails do not decrease falls, but they do decrease fall related injuries." B. "There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury." C. "Side rails are only effective when used with patients who have dementia" D. Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Correct Answer is B

Explanation

A. "Side rails do not decrease falls, but they do decrease fall-related injuries."

Explanation: While side rails may reduce the severity of injuries if a fall occurs, they are not proven to decrease the overall rate of falls. Additionally, side rails themselves can pose risks, including entrapment.

B. There is no evidence that side rail use decreases falls, and in fact, there is a greater risk of injury."

Explanation: The use of side rails as a fall prevention measure has been associated with risks and has not been shown to effectively decrease the overall rate of falls. There is evidence that side rails can contribute to injuries, including entrapment, when patients attempt to climb over or through them. The focus in fall prevention has shifted towards individualized assessments, environmental modifications, and other strategies that address the specific needs and risks of each patient.

C. "Side rails are only effective when used with patients who have dementia."

Explanation: The effectiveness of side rails is not limited to patients with dementia. However, the use of side rails as a general fall prevention strategy has been questioned, and their use should be carefully considered based on individual assessments and risks.

D. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen."

Explanation: The use of side rails is not universally proven to be effective in decreasing falls, even in patients who have previously fallen. The decision to use side rails should be based on a thorough assessment of the individual's needs and risks, considering alternatives to promote safety.

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A client care assistant has been assigned to feed your female client with dysphagia. Which of the following instructions would you give the assistant? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse wants to suggest exercise program options for an older client who is recovering losing her balance and falling. Which nursing intervention is suitable for this older adult?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

Which one of the following is connected with the nursing home reform mandated by a 1987 law?

The nurse should encourage which of the following exercise(s) to assist with balance for a client who is at high risk for falls? (Select all that apply.

Which of the following is a true statement about elimination in older adults?

As a nurse caring for a cognitively impaired older adult client, you need to observe for which of the following? (Select all that apply.)

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

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