A nurse is providing teaching for a group of clients who have dysphagia. Which of the following interventions should the nurse include?

“Use a straw to sip liquids."

“Dry swallow in between bites.”

“Mix foods of different textures into the same bite."

“Assume a chin-up position."

Answer and Explanation

The Correct Answer is B

A. “Use a straw to sip liquids.” Using a straw increases the flow of liquid, making it more difficult to control and increasing the risk of aspiration in clients with dysphagia.

B. “Dry swallow in between bites.” Performing a dry swallow between bites helps clear the throat and esophagus of any remaining food, reducing the risk of aspiration and ensuring that each bite is swallowed completely before taking another.

C. “Mix foods of different textures into the same bite.” Combining textures (e.g., liquid and solid) can confuse swallowing reflexes and increase aspiration risk. Foods should be uniform in consistency.

D. “Assume a chin-up position.” A chin-up position opens the airway and increases aspiration risk. The correct position is a chin-down (chin-tuck) posture, which helps protect the airway during swallowing.

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Correct Answer is D

Explanation

A. BMI = weight (kg) ÷ height (m²) = 75 ÷ (1.8 × 1.8) = 75 ÷ 3.24 = 23.1, which rounds to 23.

B. BMI = weight (kg) ÷ height (m²) = 75 ÷ (1.8 × 1.8) = 75 ÷ 3.24 = 23.1, which rounds to 23.

C. BMI = weight (kg) ÷ height (m²) = 75 ÷ (1.8 × 1.8) = 75 ÷ 3.24 = 23.1, which rounds to 23.

D. BMI = weight (kg) ÷ height (m²) = 75 ÷ (1.8 × 1.8) = 75 ÷ 3.24 = 23.1, which rounds to 23.

A. Perform daily weights. B. Identify thoughts that reinforce disordered eating patterns. C. Accompany the client to the restroom following meals. D. Observe the client during meals. E. Consult the dietitian to determine the client’s caloric intake. F. Use cognitive behavioral techniques to address the client’s behavior. G. Discuss measures to assist the client to develop a positive body image. H. Encourage the client to discuss feelings of new eating patterns. I. Check the client’s vital signs.

Correct Answer is ["A","C","D","I"]

Explanation

A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.

B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.

C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.

D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.

E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.

F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.

G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.

H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.

I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.

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A nurse is providing teaching for a group of clients who have dysphagia. Which of the following interventions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is calculating the BMI of a client who has a weight of 75 kg (165.3 1b) and a height of 1.8 m (5 ft 9 in). Which of the following values should the nurse calculate as the client’s BMI?

Correct Answer is D

Explanation

A nurse is caring for a client in an emergency department (ED). Exhibits The nurse reviews the Nurses’ Notes from Day 1 at 1100. Select 4 tasks the nurse should plan to delegate to the assistive personnel.

Correct Answer is ["A","C","D","I"]

Explanation

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