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?

Administer liquids to the client using a syringe.

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

Instruct the client to tilt their head back when swallowing.

Request a speech therapist consult from the provider.

Answer and Explanation

The Correct Answer is D

A) Administer liquids to the client using a syringe:

Administering liquids using a syringe may not address the underlying issue of food pocketing in the client's cheeks during meals. While syringe feeding may be necessary for clients with severe dysphagia, it does not address the need for comprehensive evaluation and intervention by a speech therapist.

B) Elevate the head of the client's bed to 45° during meals:

Elevating the head of the bed during meals is a standard intervention to help prevent aspiration in clients with dysphagia. While this intervention may be appropriate, it may not directly address the issue of food pocketing in the client's cheeks. Therefore, it is not the most comprehensive intervention for this specific problem.

C) Instruct the client to tilt their head back when swallowing:

Tilting the head back when swallowing is not a recommended intervention for clients with dysphagia. In fact, this maneuver can increase the risk of aspiration, as it can cause food or liquid to enter the airway. Therefore, this intervention would not be appropriate and could potentially exacerbate the client's swallowing difficulties.

D) Request a speech therapist consult from the provider:

This is the most appropriate intervention for addressing the client's dysphagia and food pocketing. Speech therapists are trained to assess and treat swallowing disorders, including pocketing of food in the cheeks. They can conduct a comprehensive evaluation of the client's swallowing function and develop individualized interventions to address the underlying causes of dysphagia. Therefore, requesting a speech therapist consult is the most effective way to manage this issue and improve the client's swallowing safety and efficiency.

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Correct Answer is B

Explanation

A) Establishing the priorities of client care:

Establishing priorities of client care typically occurs during the planning phase of the nursing process, not during implementation. During the planning phase, the nurse identifies the most urgent client needs based on assessments and formulates a plan of action to address those needs.

B) Reinforcing teaching about the client's diagnosis:

Reinforcing teaching about the client's diagnosis is an appropriate activity during the implementation phase of the nursing process. Implementation involves carrying out the planned interventions, which may include educating the client about their diagnosis, treatment plan, and self-care strategies. Reinforcing teaching ensures that the client understands their condition and how to manage it effectively.

C) Asking the client about the presence of pain:

Assessing the client for pain is typically part of the assessment phase of the nursing process, not the implementation phase. During assessment, the nurse gathers data about the client's pain experience, including location, intensity, quality, and factors that alleviate or exacerbate pain.

D) Comparing the client's current laboratory values to previous results:

Comparing laboratory values is a component of data interpretation and analysis, which occurs primarily during the evaluation phase of the nursing process. While the nurse may review laboratory values during implementation to monitor the client's response to interventions, comparing current values to previous results is more closely associated with evaluating the effectiveness of care provided.

A. Includes quotes from the client B. Remains logged in to the charting system throughout the shift C. Makes reference in the nurses notes of completing an incident report D. Documents that the provider wrote an inaccurate prescription

Correct Answer is A

Explanation

A) Includes quotes from the client:

Including direct quotes from the client in documentation provides accurate information about the client's statements or expressions. This practice enhances the clarity and validity of the documentation, as it captures the client's own words, which may be important for conveying their thoughts, feelings, or symptoms.

B) Remains logged in to the charting system throughout the shift:

Remaining logged in to the charting system throughout the shift poses a security risk and violates principles of confidentiality. Nurses should log out of the system when not actively using it to prevent unauthorized access to sensitive patient information.

C) Makes reference in the nurse's notes of completing an incident report:

While documenting the completion of an incident report is important for communication and quality improvement purposes, referencing it directly in the nurse's notes may not be appropriate. Incident reports are typically separate documents used for reporting adverse events or incidents, and their contents may not be part of the client's medical record.

D) Documents that the provider wrote an inaccurate prescription:

Documenting that the provider wrote an inaccurate prescription is not within the scope of a nurse's documentation responsibilities. If a nurse identifies an inaccurate prescription, the appropriate action is to clarify the prescription with the provider through established communication channels rather than documenting the error in the client's chart.

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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?

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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?