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 D

Explanation

A. Assist the client to make autonomous decisions about his treatment options. Assisting the client to make autonomous decisions is important, but it cannot be done effectively until the client is aware of his diagnosis. This action would follow once the client is informed.
B. Reflect on her own opinion about withholding the diagnosis from him. Reflecting on her own opinion can help the nurse understand her biases but does not directly address the family's request or the client's immediate needs.
C. Inform the family that he has a legal right to be informed of his diagnosis. Informing the family about the client's legal right is essential, but first, the nurse should understand the family's perspective and concerns.
D. Determine the family's reasons for not telling him about his diagnosis. This is correct. Understanding the family's reasons provides context and helps the nurse address their concerns appropriately while advocating for the client’s right to know his diagnosis.

A. Keeping a record of dry nights in a daily diary B. Beginning medication therapy to inhibit urination C. Using an alarm to wake the child at the onset of urination D. Using stickers as positive reinforcement for dry nights

Correct Answer is C

Explanation

A. Keeping a record of dry nights in a daily diary: This can be helpful for tracking progress but is not the most effective intervention for treating enuresis.
B. Beginning medication therapy to inhibit urination: Medication can be used in some cases, but it is typically not the first-line treatment for enuresis.
C. Using an alarm to wake the child at the onset of urination: This is correct. Bedwetting alarms are considered the most effective intervention for treating enuresis. They condition the child to wake up or hold urine when the bladder is full.
D. Using stickers as positive reinforcement for dry nights: This can be useful as part of a behavioral approach but is not as effective as using a bedwetting alarm.

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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?

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