A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Elevate the head of the client's bed to 45" during meals.

Request a speech therapist consult from the provider.

Instruct the client to tilt their head back when swallowing.

Administer liquids to the client using a syringe.

Answer and Explanation

The Correct Answer is B

A.   Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B.   Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C.   Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D.   Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.

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Correct Answer is A

Explanation

A. "I do not want to have any surgery for my cancer." This indicates the client's decision to refuse treatment, and the nurse should advocate by respecting and supporting the client's autonomy.
B. "I have contacted another surgeon to get a second opinion." Seeking a second opinion demonstrates proactive decision-making and does not require advocacy.
C. "I will discuss treatment options next week after thinking about this." The client is demonstrating autonomy by requesting time to consider options.
D. "I will take chemotherapy since my family wants me to." This indicates external pressure rather than autonomous decision-making, necessitating the nurse's role as an advocate.

A. Asking a staff member from another unit to complete the evaluation B. Linking the evaluation to predetermined standards C. Focusing primarily on areas that need improvement D. Discussing the evaluation with the nurse manager

Correct Answer is B

Explanation

A. Asking a staff member from another unit to complete the evaluation: Staff from other units may not have direct knowledge of the nurse's work performance.
B. Linking the evaluation to predetermined standards: Using predetermined standards ensures objectivity and consistency in evaluations.
C. Focusing primarily on areas that need improvement: Evaluations should be balanced, recognizing both strengths and areas for improvement.
D. Discussing the evaluation with the nurse manager: The evaluation should first be completed independently before discussing it with a manager if needed.

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A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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