A nurse is performing eye care for a client who is in a coma. Which of the following actions should the nurse take? (Select all that apply.)

Choice A Reason:

Administering sedative medication should not be the first action. It is important to assess the client's level of comfort and understand the reason for pulling on the NG tube before considering sedation. Sedation may mask underlying issues, and the goal is to address the cause of the behavior.

Choice B Reason:

Assessing the client's level of comfort is the priority. Understanding the reason for pulling on the NG tube is crucial before implementing interventions. The client may be experiencing pain, discomfort, anxiety, or another issue that needs to be addressed.

Choice C Reason:

Applying a restraint should be a last resort and is not the initial action. Restraints are used to ensure safety when other measures have failed. The priority is to address the underlying cause and promote comfort without resorting to restraint.

Choice D Reason:

Documenting the client's behavior is important for the medical record, but it comes after assessing and addressing the immediate needs of the client. Understanding the context and reasons for the behavior is crucial for accurate documentation.

Choice Reason:
Occupational Therapist is incorrect. Occupational therapists focus on helping individuals regain or enhance their ability to perform daily activities and tasks. While they might not directly address dysphagia or swallowing concerns, they could assist in modifying the environment or providing adaptive equipment to facilitate eating, such as recommending specialized utensils or adapting seating positions to support safe eating practices.

Choice B Reason:
Physical Therapist is incorrect. Physical therapists primarily concentrate on restoring mobility, strength, and function in individuals who have experienced injuries or illnesses affecting movement. While they might not directly address dysphagia, they could be involved in helping patients with postural adjustments or exercises that indirectly support safe eating and swallowing.

Choice C Reason:
Respiratory Therapist is incorrect. Respiratory therapists specialize in assessing and treating breathing problems and disorders related to the lungs and respiratory system. While they may not focus directly on dysphagia, they can be involved in managing respiratory complications that can arise from aspiration, such as pneumonia. They might assist in suctioning, breathing exercises, or respiratory treatments in cases where aspiration has led to lung issues.

Choice D Reason:
Speech therapists, also known as speech-language pathologists, is correct because it specializes in evaluating and treating communication and swallowing disorders. They work with individuals who have experienced strokes or other conditions affecting swallowing abilities to improve their swallowing function and reduce the risk of aspiration (when food or liquid enters the airway instead of the digestive tract).