A nurse is assisting a client who has dysphagia at meal time. Which of the following actions should the nurse take?

Ask the client to tilt her head back when swallowing.

Offer the client larger portions of food during the meal.

Use spoons, instead of cups, when serving liquids to the client.

Encourage the client to complete the meal within 15 min.

Answer and Explanation

The Correct Answer is C

A. Ask the client to tilt her head back when swallowing. Tilting the head back can increase the risk of aspiration. Clients with dysphagia should be instructed to tuck their chin to their chest when swallowing.
B. Offer the client larger portions of food during the meal. Smaller portions are safer for clients with dysphagia to reduce the risk of choking and aspiration.
C. Use spoons, instead of cups, when serving liquids to the client. This is correct. Using spoons can help control the amount of liquid the client receives, reducing the risk of aspiration.
D. Encourage the client to complete the meal within 15 min. Rushing a meal increases the risk of choking and aspiration. Clients with dysphagia should eat slowly and take small bites.

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Correct Answer is ["A","D"]

Explanation

A. Place the client in contact isolation. Contact isolation helps prevent the spread of C. difficile to other patients and staff by requiring the use of gowns and gloves when entering the patient's room.
B. Prepare the client for a colonoscopy. This is not typically part of the standard care plan for C. difficile infection. Colonoscopies are not indicated for diagnosing or managing C. difficile.
C. Administer docusate sodium 500 mg daily. Docusate sodium is a stool softener and is not appropriate for treating C. difficile, which causes diarrhea.
D. Use a bleach solution to clean the client's bedside table. Bleach is effective at killing C. difficile spores, which are resistant to many other cleaning agents.
E. Use hand sanitizer immediately after caring for the client. Hand sanitizers are not effective against C. difficile spores. Handwashing with soap and water is necessary.

A. Provide an analgesic for pain. B. Obtain a self-report from the client. C. Observe the client's behaviors. D. Develop a behavioral pain score.

Correct Answer is B

Explanation

A. Provide an analgesic for pain. Administering medication is important but should be done after assessing the pain.
B. Obtain a self-report from the client. The client's self-report is the most reliable indicator of pain and should be obtained first.
C. Observe the client's behaviors. Observing behaviors is helpful but should follow the self-report to validate the client's experience.
D. Develop a behavioral pain score. This can be useful for non-verbal clients, but the self-report is the primary method of assessment for verbal clients.

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A nurse is assisting a client who has dysphagia at meal time. Which of the following actions should the nurse take?

Nursing Test Bank

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