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.
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Related Questions
Correct Answer is C
Explanation
A. Occupational therapist:
While occupational therapists play a valuable role in stroke rehabilitation, they typically focus on activities of daily living (ADLs), upper extremity function, and adaptive strategies. In the context of frequent coughing during swallowing, the expertise of an SLP is more directly relevant to address potential dysphagia.
B. Physical therapist:
Physical therapists primarily focus on mobility, strength, and balance. While they may be involved in stroke rehabilitation, the issue of coughing during swallowing is more aligned with the scope of practice of a speech-language pathologist.
C. Speech-language pathologist:
This is the correct answer. A speech-language pathologist (SLP) specializes in assessing and treating communication and swallowing disorders. In this case, the client is experiencing coughing when swallowing, indicating a potential swallowing (dysphagia) issue. The SLP can conduct a thorough evaluation of the client's swallowing function and recommend appropriate interventions, such as swallowing exercises or modified diets, to address the coughing and improve safe swallowing.
D. Social worker:
Social workers provide support for psychosocial and community-related issues. While they are crucial members of the interdisciplinary team, they may not have the specific expertise needed to address the swallowing difficulties experienced by the client after a stroke
Correct Answer is D
Explanation
A. Elevate full-length side rails on both sides of the client's bed:
While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.
B. Place the bedside table 0.9 m (3 feet) away from the bed:
Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.
C. Keep the client's room temperature at 18°C (64.4°F):
While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.
D. Provide the client with a night light:
This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.
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