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. Observe the client's verbal and nonverbal behaviors. Observing nonverbal cues helps assess understanding and emotional responses when there is a language barrier.
B. Ask the client's adolescent child to act as an interpreter. Family members, especially minors, should not interpret due to confidentiality and potential inaccuracies.
C. Avoid the use of gestures. Gestures can be helpful when used appropriately, though cultural considerations are necessary.
D. Speak directly to the interpreter. The nurse should speak directly to the client, even when an interpreter is present, to maintain rapport and respect.

A. Close the door to the client's room. B. Activate the alarm outside the client's room. C. Use a Class A fire extinguisher to contain the fire. D. Turn off electrical equipment in the client's room.

Correct Answer is B

Explanation

A. Close the door to the client's room: This helps contain the fire and prevents smoke from spreading, but it should not be the immediate action after client removal.
B. Activate the alarm outside the client's room: Activating the alarm is critical after ensuring the client's safety, as it alerts the facility to the emergency and mobilizes response teams.
C. Use a Class A fire extinguisher to contain the fire: The type of extinguisher used depends on the fire classification. Attempting to extinguish a fire should occur only after the alarm is activated.
D. Turn off electrical equipment in the client's room: While turning off electrical equipment can reduce fire hazards, it is not the next priority after removing the client.

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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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