A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
The client tucks their chin when they swallow.
The client adjusts the head of their bed to 90°.
The client drinks their thickened juice with a straw.
The client takes frequent breaks while eating.
The Correct Answer is C
A. The client tucks their chin when they swallow:
This is a proper swallowing technique. Tucking the chin helps close off the airway during swallowing, reducing the risk of aspiration. It facilitates the safe passage of food or liquids into the esophagus
B. The client adjusts the head of their bed to 90°:
This action is appropriate. Keeping the head of the bed elevated to 30 to 45 degrees is recommended for clients with dysphagia as it helps prevent aspiration during swallowing.
C. The client drinks their thickened juice with a straw:
This action indicates a potential problem. The use of a straw with thickened liquids is generally not recommended for clients with dysphagia. Thickened liquids are used to slow down the flow of the liquid and reduce the risk of aspiration. Drinking thickened juice through a straw may compromise the effectiveness of thickening and increase the risk of aspiration.
D. The client takes frequent breaks while eating:
This action is also appropriate. Clients with dysphagia may need to take breaks between bites to ensure safe and effective swallowing. It allows the client to pace themselves and reduces the risk of aspiration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It's nice having other people cook for me.":
This statement suggests adaptation to the new situational role. The client expresses a positive view of receiving help and support in daily activities, indicating a level of acceptance and adjustment to the changed living situation.
B. "I've never been the kind of person to ask others for help.":
This statement suggests a reluctance to seek help, and it may indicate a struggle with the new situational role. Adaptation often involves a willingness to accept assistance and support from others when needed.
C. "I'm looking forward to being able to be independent again.":
This statement indicates a positive attitude toward regaining independence, but it may not necessarily indicate full adaptation to the new situational role. The client is expressing a future orientation, and the actual adaptation will be evident when independence is achieved.
D. "I really don't know what I'm supposed to do all day.":
This statement suggests confusion or uncertainty about the daily routine, which may indicate a lack of adjustment to the new living situation. Adaptation involves a sense of understanding and comfort with one's roles and activities.
Correct Answer is A
Explanation
A. "I will walk three times per week."
Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.
B. "I will take 250 milligrams of calcium once per day."
This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.
C. "I will decrease my intake of dairy products."
Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.
D. "I will avoid exposure to the sun."
Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.
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