A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
Providing a 10 min rest period prior to meals
Elevating the head of the client’s bed to 30 degrees during mealtime
Instructing the client to place her chin toward her chest when swallowing
Withholding fluids until the end of the meal
The Correct Answer is C
a. Providing a 10-minute rest period prior to meals:
This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime:
The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.
c. Instructing the client to place her chin toward her chest when swallowing:
This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.
d. Withholding fluids until the end of the meal:
Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.
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Related Questions
Correct Answer is C
Explanation
a. Ask the client if she would like a sedative to help her relax:
Offering a sedative may not address the underlying reasons for the client's desire to leave. Moreover, administering a sedative without addressing the client's concerns or obtaining informed consent would not be appropriate.
b. Inform the client that she cannot leave without a discharge prescription from the provider:
While informing the client of the discharge process is important, presenting this information as a restriction may not be the most therapeutic approach. Additionally, in many healthcare settings, patients have the legal right to leave against medical advice, so presenting it as a requirement may not be accurate.
c. Have the client sign the Against Medical Advice form:
When a client decides to leave against medical advice, it is standard practice to have them sign an Against Medical Advice (AMA) form. This form documents the client's decision and acknowledges that they are leaving the hospital against the advice of the healthcare provider.
d. Assign a security officer to the client's room until the provider can speak with the client:
Assigning a security officer may be appropriate in situations where there are concerns for the safety of the client or others, such as if the client is agitated or threatening harm. However, in this scenario, the client has expressed a desire to leave, and assigning a security officer may escalate the situation unnecessarily.
Correct Answer is A
Explanation
a. “The client is in the radiology department for a chest x-ray.”
This information is relevant as it informs the oncoming nurse about the client's current location and the reason for the absence from the unit. It helps maintain awareness of the client's whereabouts and the ongoing diagnostic process.
b. “The client’s partner came to visit him 2 hrs. ago.”
While it's important to document visitor interactions in the client's chart, informing about a visit from 2 hours ago during a change-of-shift report may not be as pertinent to immediate patient care as other information. This detail can be communicated through other means, such as the client's chart or communication log.
c. “The client has routine vital signs prescribed.”is not as critical to include in the change-of-shift report because it is standard practice and does not provide specific, immediate information about the client’s current status or any changes that need to be monitored closely.
d. “The client is the president of a local bank.”
While interesting, this information is not relevant to the client's current medical condition or care plan. It does not contribute to the immediate care needs of the client and can be considered extraneous during a change-of-shift report.
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