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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
a. Educate the client about the risks of refusing the procedure:
This option suggests providing information about the potential consequences of not undergoing the gastroscopy. While educating the client about risks is essential, the immediate concern is the client's lack of understanding about the procedure itself.
b. Complete the incident report:
Filling out an incident report is typically reserved for situations where there has been an actual incident, such as a medical error or adverse event. In this case, the client's lack of understanding does not constitute an incident but rather a need for clarification.
c. Inform the provider that the client requires clarification about the procedure:
This is the correct action. It involves escalating the issue to the provider responsible for performing the gastroscopy. The provider can then address the client's concerns, answer questions, and provide additional information to ensure informed consent.
d. Answer the client’s questions concerning the procedure:
While answering the client's questions is important, it's not solely the nurse's responsibility to ensure the client understands the procedure. The provider, who will perform the gastroscopy, should be informed of the client's confusion so they can address it effectively.
Correct Answer is B
Explanation
a. A system for tracking client information:
Having a system for tracking client information is essential for effective disaster management, including during bioterrorism events. This system allows healthcare providers to monitor and manage the care of affected individuals, track exposure to biological agents, and coordinate response efforts. It facilitates communication and collaboration among healthcare teams and enables timely and accurate documentation of patient information, including symptoms, treatment, and outcomes.
b. A sufficient supply of personal protective equipment (PPE):
Personal protective equipment is critical in protecting healthcare workers and first responders from exposure to biological agents during a bioterrorism event. PPE includes items such as masks, gloves, gowns, and eye protection, which create a barrier between individuals and potentially hazardous substances. Having an adequate supply of PPE ensures that healthcare providers can safely care for affected individuals, minimize the risk of infection or contamination, and prevent the spread of disease within healthcare settings and the community.
c. A mental health specialist on the response team:
A mental health specialist plays a vital role in addressing the psychological and emotional needs of individuals affected by a bioterrorism event. Such events can cause fear, anxiety, trauma, and grief among survivors, healthcare workers, and the community. A mental health specialist provides support, counseling, and crisis intervention to help individuals cope with stress, trauma, and loss. They also assist in addressing psychosocial factors that may impact recovery and resilience, such as social support, coping mechanisms, and access to mental health services.
d. A network for communication between staff members and families:
Effective communication is essential for coordinating response efforts, disseminating information, and providing updates to staff members, patients, and their families during a bioterrorism event. A network for communication facilitates real-time communication and collaboration among healthcare teams, emergency responders, public health agencies, and community partners. It enables the sharing of critical information, such as situational updates, safety protocols, resource allocation, and instructions for affected individuals and their families. This communication network ensures that everyone receives timely and accurate information, reduces uncertainty and confusion, and enhances overall coordination and response effectiveness.
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