A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Ask the client to tilt their head back when swallowing.

Have the client sit upright for 1 hr following meals.

Administer liquids to the client using a syringe.

Allow the client to rest for 10 min prior to eating.

Answer and Explanation

The Correct Answer is B

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

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Correct Answer is B

Explanation

A. "I can exercise as late as 1 hour before bedtime." Exercise close to bedtime can increase alertness and make it harder to fall asleep. It is recommended to finish exercising at least 3-4 hours before bedtime.

B. "I should reduce my fluid intake 2 hours before bedtime." Reducing fluid intake before bedtime helps minimize nocturia, which can disrupt sleep.

C. "I should take a 1-hour nap each day." Long or frequent naps can interfere with nighttime sleep. If naps are needed, they should be limited to 20-30 minutes earlier in the day.

D. "I can eat a large meal as late as 1 hour before bedtime." Eating a heavy meal before bed can cause discomfort and acid reflux, which may disrupt sleep. A light snack is preferable.

A. Turn on the bed alarm. B. Maintain the bed in the lowest position. C. Place the client in a vest restraint. D. Administer a sedative. E. Encourage the family to stay with the client.

Correct Answer is ["A","B","E"]

Explanation

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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