A nurse is supervising 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?
Providing a 10min 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 B
a. Providing a rest period prior to meals may be appropriate for some clients, but 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 helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c. Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d. Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. An evidence-based nursing journal would provide reliable, peer-reviewed information on the prevalence of Tay-Sachs disease, ensuring accuracy and reliability.
b. While the client's health care provider may have general knowledge about Tay-Sachs disease, they may not have specific prevalence statistics readily available.
c. The facility's case manager may assist with coordination of care but may not have specific information about the prevalence of Tay-Sachs disease.
d. Collaborative, user-edited websites may not always provide accurate or reliable information, so they should be used with caution for obtaining medical information.
Correct Answer is A
Explanation
a. Decreased level of consciousness is a critical finding in a client with meningitis and may indicate worsening intracranial pressure or neurological deterioration, requiring immediate intervention.
b. While an increased temperature may indicate infection, it is not as immediately concerning as a decreased level of consciousness in a client with meningitis.
c. A generalized rash over the trunk may be present in some types of meningitis, but it is not as immediately urgent as a decreased level of consciousness.
d. Photophobia (sensitivity to light) is a common symptom of meningitis but may not require immediate intervention unless accompanied by other concerning neurological findings such as a decreased level of consciousness.
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