A nurse in a rehabilitation facility is assisting in the care of a client who was admitted the previous day.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Aspiration (Option 1): The client's report of feeling food stuck in their mouth, along with the noted hoarseness, indicates difficulty swallowing (dysphagia), which puts them at risk for aspiration. Aspiration occurs when food or liquid enters the airway instead of the esophagus, which can lead to serious complications, including pneumonia.
Dysphagia (Option 2): The presence of dysphagia, or difficulty swallowing, directly supports the risk for aspiration. If the client is unable to swallow safely, there is an increased likelihood of aspiration occurring during eating or drinking.
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Correct Answer is C
Explanation
A. While a witness may be required, it does not have to be a family member and may vary by state law.
B. Advance directives specify health care preferences, not organ donation, which usually requires a separate directive.
C. Naming a family member, like a sibling, as a designee in a durable power of attorney for health care is appropriate and is part of ensuring that health care decisions align with the client’s wishes if they become unable to communicate.
D. Advance directives do not require an attorney’s approval to be valid; they are enforced based on the client’s wishes as documented.
Correct Answer is A
Explanation
A. Applying the restraint over the client’s gown protects the skin and ensures comfort.
B. Restraints should never be tied to the side rail as it could lead to injury if the bed is adjusted; they should be tied to a stable part of the bed frame.
C. Skin integrity should be checked more frequently than every 4 hours to prevent injury.
D. Typically, two fingers, not four, should fit between the restraint and the client’s body to ensure it’s secure but not too tight.
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