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 ["A","C","E"]

Explanation

A. Ensure the cane has a rubber cap. A rubber cap provides stability and prevents slipping, reducing fall risk.

B. Hold the cane on the weaker side. The cane should be held on the stronger side to provide support while stepping forward with the weaker leg.

C. Flex the elbow slightly when using the cane. The elbow should be slightly flexed (15-30 degrees) when holding the cane for optimal support and comfort.

D. Move the cane and stronger leg forward simultaneously. The cane and weaker leg should move forward together to maintain balance, followed by the stronger leg stepping forward.

E. Use a quad cane for increased support. A quad cane provides a broader base of support and is recommended for clients who need extra stability.

A. Numerical pain scale B. Verbal description C. FACES pain scale D. Behavioural indicators

Correct Answer is D

Explanation

A. Numerical pain scale. Clients with dementia often have difficulty understanding and using numerical pain scales.

B. Verbal description. Many clients with dementia have impaired verbal communication, making it difficult to describe pain effectively.

C. FACES pain scale. While this scale is useful for some nonverbal populations, it still requires the client to actively choose a face, which may be difficult for those with advanced dementia.

D. Behavioral indicators. Observing facial expressions, body movements, vocalizations, and changes in vital signs can help assess pain in clients who cannot self-report. The PAINAD (Pain Assessment in Advanced Dementia) scale is commonly used.

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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

A nurse is teaching a client about the correct use of a cane. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

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

Explanation

A nurse is assessing the pain level of a client who has dementia and difficulty communicating. Which of the following pain assessment techniques should the nurse use?

Correct Answer is D

Explanation

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