A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
Withholding fluids until the end of the meal
Elevating the head of the client's bed to 30 degrees during mealtime
Providing a 10-minute rest period prior to meals
Instructing the client to place her chin toward her chest when swallowing
The Correct Answer is D
Choice A reason: This is not a correct technique for feeding a client who has dysphagia. Withholding fluids until the end of the meal can increase the risk of dehydration and aspiration. Fluids should be offered throughout the meal to help moisten and thin the food.
Choice B reason: This is not a correct technique for feeding a client who has dysphagia. Elevating the head of the client's bed to 30 degrees during mealtime is not enough to prevent aspiration. The client should be in an upright position, preferably at 90 degrees, to facilitate swallowing and gravity.
Choice C reason: This is not a correct technique for feeding a client who has dysphagia. Providing a 10-minute rest period prior to meals is not necessary and may delay the feeding. The client should be fed when they are alert and hungry, and not too tired or sleepy.
Choice D reason: This is a correct technique for feeding a client who has dysphagia. Instructing the client to place her chin toward her chest when swallowing can help close the airway and prevent food from entering the lungs. This can reduce the risk of aspiration and choking.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct response by the nurse. The nurse should respect the client's right to privacy and confidentiality and not disclose any information about the client's treatment plan without the client's consent. The nurse should also inform the adult child that they can ask their mother for permission to access her medical records.
Choice B reason: This is not the correct response by the nurse. The nurse should not ask the adult child what they want to know about the client's treatment, as this implies that the nurse is willing to share the information without the client's consent. The nurse should only answer the questions that the client has authorized the nurse to answer.
Choice C reason: This is not the correct response by the nurse. The nurse should not tell the adult child to speak directly to their mother about her treatment, as this may put pressure on the client to reveal information that she may not want to share. The nurse should respect the client's autonomy and decision-making regarding her treatment plan.
Choice D reason: This is not the correct response by the nurse. The nurse should not ask the client's primary care provider to speak with the adult child, as this may violate the client's privacy and confidentiality. The nurse should only involve the primary care provider if the client has given consent or if there is a legal or ethical obligation to do so.
Correct Answer is D
Explanation
Choice A reason: This is not the correct choice because low pain tolerance is not the most urgent issue to address. The client may experience some pain and discomfort after the surgery, but this can be managed with medication and non-pharmacological interventions. The nurse should educate the client on how to use pain scales, request pain relief, and apply ice packs or heat pads as needed.
Choice B reason: This is not the correct choice because decreased self-esteem is not the most urgent issue to address. The client may have some negative feelings about their appearance or abilities after the surgery, but this can be improved with counseling and support groups. The nurse should encourage the client to express their emotions, focus on their strengths, and seek professional help if necessary.
Choice C reason: This is not the correct choice because limited social support is not the most urgent issue to address. The client may have difficulty coping with the recovery process and the lifestyle changes required after the surgery, but this can be alleviated with community resources and referrals. The nurse should assess the client's social network, provide information on local agencies and organizations, and arrange for home health care or visiting nurses if needed.
Choice D reason: This is the correct choice because inadequate food supply is the most urgent issue to address. The client needs to have access to nutritious and balanced meals to promote healing and prevent complications after the surgery. The nurse should evaluate the client's food security, provide food vouchers or coupons, and connect the client with food banks or meal delivery services.
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