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 D

Explanation

A) Triclosan:

Triclosan is an antimicrobial agent commonly found in soaps, hand sanitizers, and other personal care products. While it has broad-spectrum antimicrobial properties, it is not specifically recommended for hand hygiene in the context of C. difficile infection. Alcohol-based antiseptic rubs are preferred due to their rapid and effective action against C. difficile spores.

B) Chlorhexidine gluconate:

Chlorhexidine gluconate is an antimicrobial agent commonly used as a surgical scrub and skin cleanser. While it is effective against a wide range of microorganisms, including bacteria and fungi, its efficacy against C. difficile spores is limited compared to alcohol-based antiseptic rubs. Therefore, it is not the preferred choice for hand hygiene in the context of C. difficile infection.

C) Alcohol-based antiseptic rub:

Hand hygiene is crucial in preventing the transmission of Clostridium difficile, a bacterium that can cause severe gastrointestinal infection. Alcohol-based antiseptic rubs are not highly effective against C. difficile spores. Thorough handwashing with soap and water has demonstrated superior antimicrobial activity compared to alcohol-based rubs and are preferred for hand hygiene in such situations.

D) Non-antimicrobial soap:

Clostridium difficile (C. difficile) is a bacterium that can cause severe gastrointestinal infection, and proper hand hygiene is essential in preventing its transmission. While alcohol-based antiseptic rubs are effective against many pathogens, including C. difficile, non-antimicrobial soap and water are preferred for hand hygiene after caring for a client with C. difficile. Non-antimicrobial soap helps to mechanically remove C. difficile spores from the hands, reducing the risk of transmission. Although alcohol-based rubs are convenient and effective in many situations, they may not be as effective as soap and water for removing spores and should be used in conjunction with thorough handwashing when caring for clients with C. difficile.

A. I will take chemotherapy since my family wants me to B. I will discuss treatment options next week after thinking about this." C. I do not want to have any surgery for my cancer. D. I have contacted another surgeon to get a second opinion."

Correct Answer is A

Explanation

A) I will take chemotherapy since my family wants me to:

This statement indicates a potential lack of autonomy and decision-making by the client. The nurse should act as a client advocate by ensuring that the client's decisions regarding treatment are based on their own wishes, values, and preferences, rather than solely on the desires of others.

B) I will discuss treatment options next week after thinking about this:

This statement demonstrates the client's intent to participate in the decision-making process regarding their treatment options. While it indicates autonomy and contemplation, it does not necessarily require the nurse to act as a client advocate at this time.

C) I do not want to have any surgery for my cancer:

This statement reflects the client's autonomy and preference regarding their treatment plan. While the nurse should respect the client's decision, it does not directly prompt the nurse to act as a client advocate.

D) I have contacted another surgeon to get a second opinion:

This statement shows the client's proactive approach to gathering additional information about their treatment options, which is commendable. However, it does not specifically indicate a need for the nurse to advocate for the client's rights or preferences.

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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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