A nurse is ordering a breakfast meal tray for a client who has dysphagia and a prescription for a mechanically altered diet. Which of the following foods should the nurse select?

Yogurt and granola

Wheat toast with butter

Pancakes with syrup

Banana and nut muffin

Answer and Explanation

The Correct Answer is C

A. Yogurt and granola is not appropriate because granola is hard and can be difficult to swallow, increasing the risk of aspiration.
B. Wheat toast with butter is not appropriate because toast is dry and can be difficult to chew and swallow, posing a choking hazard.
C. Pancakes with syrup are soft and easy to chew, making them a suitable choice for a mechanically altered diet. The syrup adds moisture, further aiding swallowing.
D. Banana and nut muffin is not appropriate because muffins can be dry and crumbly, and nuts are a choking hazard for clients with dysphagia.

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Correct Answer is C

Explanation

A. The client has been in the restraints for 4 hr. This is incorrect because the duration of restraint use is determined by the client's behavior and safety, not a set time frame. Restraints should be discontinued as soon as they are no longer necessary.
B. The client can explain the reasons for their behavior. This is incorrect because insight into behavior does not necessarily indicate that the client is no longer a danger to themselves or others.
C. The client is able to calmly follow commands. This is correct because the primary indication for removing restraints is when the client demonstrates self-control and the ability to follow directions, reducing the risk of harm.
D. The client reports that the restraints are too tight. This is incorrect because a complaint of tight restraints indicates a need for reassessment and possible adjustment, but not necessarily discontinuation.

A. Document in the client's medical record if the client has advance directives. B. Ensure the client has an attorney to contact for assistance with end-of-life documents. C. Provide end-of-life education if the client has a terminal illness. D. Provide the client with a list of eligible individuals who can serve as a health care proxy.

Correct Answer is A

Explanation

A. The Patient Self-Determination Act (PSDA) requires health care facilities to ask clients about advance directives upon admission and document their status in the medical record. This ensures that the client’s treatment preferences are known and respected.
B. Ensuring the client has an attorney is not a requirement of the PSDA. Clients may choose legal assistance, but it is not mandated by the act.
C. Providing end-of-life education is beneficial but not specifically required by the PSDA. The act focuses on informing clients of their rights regarding advance directives.
D. The PSDA does not require facilities to provide a list of eligible health care proxies. Instead, it ensures clients are informed of their right to appoint one.

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A nurse is ordering a breakfast meal tray for a client who has dysphagia and a prescription for a mechanically altered diet. Which of the following foods should the nurse select?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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