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

Answer and Explanation

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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Correct Answer is C

Explanation

a. Is the client’s family present so the AP can show them how to turn the client:

While involving the client's family in care can be beneficial for education and support, this assessment does not directly pertain to the AP's ability to provide care or the client's immediate needs.

b. Does the AP have time to change the client’s central IV-line dressing after turning her:

This assessment is relevant to the AP's workload and scheduling, but it does not directly address the client's care needs related to bathing and turning.

c. Has data been collected about specific client needs related to turning:

This assessment is crucial before delegating care. The nurse should ensure that relevant information about the client's condition, including any specific needs or considerations related to turning, has been gathered and communicated to the AP to provide appropriate care.

d. Has the AP checked the client’s pain level prior to turning her:

This assessment is essential to ensure the client's comfort and safety during care activities. Assessing the client's pain level before turning helps prevent exacerbation of pain and ensures that turning is performed with appropriate consideration for the client's comfort.

A. Assault B. Libel C. Battery D. False Imprisonment

Correct Answer is C

Explanation

a. Assault:

Assault involves the threat of bodily harm or unwanted physical contact that creates fear or apprehension in the victim. In this scenario, there is no indication of a threat being made against the client; instead, the nurse administers the medication without their consent.

b. Libel:

Libel refers to a false written statement that damages a person's reputation. This option is not applicable to the scenario described, as it does not involve written communication or defamation of character.

c. Battery:

Battery occurs when there is unauthorized physical contact with another person that results in harm or offense. In this scenario, the nurse administers the injection against the client's will, which constitutes unauthorized physical contact, making it an example of battery.

d. False imprisonment:

False imprisonment involves unlawfully restraining or confining a person against their will. While administering medication without consent could potentially be perceived as a form of restraint, false imprisonment typically involves physical confinement or restriction of movement, which is not the case in this scenario.

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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?

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