A nurse is assessing the skin turgor of an older adult client. In which of the following areas should the nurse lift the skin?

Rationale:

A. Sit at or below the client's eye level during feedings: Positioning the nurse at or slightly below the client’s eye level promotes effective communication and allows close observation of swallowing. It helps the nurse monitor for signs of aspiration, coughing, or choking, which is critical in clients with dysphagia to ensure safety during meals.

B. Instruct the client to lift her chin when swallowing: Clients with dysphagia should be taught to tuck the chin slightly toward the chest, not lift it, to protect the airway and facilitate safer swallowing. Lifting the chin increases the risk of aspiration and airway compromise.

C. Talk with the client during her feeding: Talking while swallowing increases the risk of aspiration because it distracts the client and can disrupt coordinated swallowing. Silence and focused attention are recommended during feeding to ensure safe intake of food and liquids.

D. Discourage the client from coughing during feedings: Coughing is a protective reflex that clears the airway if food or liquid enters the trachea. Discouraging it could increase the risk of aspiration and choking, making it unsafe to suppress this natural defense mechanism.

Rationale:

A. Arrange for a meeting with the child's guardians tomorrow: Meeting with the guardians may be appropriate later, but initially, the nurse must follow mandatory reporting laws. Waiting to meet could delay protection for the child and place them at further risk.

B. Notify the president of the school board: Reporting to school administration does not replace legal obligations to report suspected child abuse. The school board president is not the appropriate authority for immediate child protection.

C. Ask the child's peers about the bruises: Questioning peers is inappropriate and could violate privacy or compromise the investigation. The nurse should not attempt to investigate the situation personally.

D. Report the findings to child protective services: As a mandated reporter, the nurse is legally required to report any suspected child abuse immediately to child protective services. This action ensures the child’s safety and initiates an official investigation.