A nurse is contributing to the plan of care for a client who has dysphagia and is pocketing food in their cheeks during meals. Which of the following interventions should the nurse recommend?
Elevate the head of the client's bed to 45" during meals.
Request a speech therapist consult from the provider.
Instruct the client to tilt their head back when swallowing.
Administer liquids to the client using a syringe.
The Correct Answer is B
A. Elevate the head of the client's bed to 45° during meals: The head should be elevated to 90° to reduce the risk of aspiration during meals.
B. Request a speech therapist consult from the provider: Speech therapists can assess swallowing difficulties and recommend appropriate strategies.
C. Instruct the client to tilt their head back when swallowing: This position increases the risk of aspiration by opening the airway during swallowing.
D. Administer liquids to the client using a syringe: Syringe administration can lead to choking or aspiration and is not a standard feeding practice for dysphagia clients.
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Related Questions
Correct Answer is D
Explanation
A. A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective: This does not meet the criteria for slander, as it involves a potential clinical plan of care rather than false statements.
B. A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired: Communication during a private meeting does not constitute slander.
C. A nurse documents that a client was shouting and directly quotes the client's words: Documenting client behavior accurately in the medical record does not qualify as slander.
D. A client overhears an assistive personnel make a false statement about the assigned nurse and requests a different nurse: Slander involves making false verbal statements that harm someone's reputation. If overheard, this constitutes slander.
Correct Answer is ["B","C","D"]
Explanation
A. Place throw rugs on uncarpeted floors in the client's home. Throw rugs are a tripping hazard and should be removed or secured.
B. Ensure the client wears non-skid slippers when walking around the house: Non-skid slippers provide traction and reduce the risk of slipping.
C. Encourage an annual review of the medications the client is taking. Many medications can cause dizziness or sedation, increasing fall risk, so regular medication reviews are essential.
D. Install a raised toilet seat in the client's bathroom. A raised toilet seat makes it easier for older adults to use the toilet and reduces the risk of falls when standing or sitting.
E. Attach full-length side rails to the client's bed. Full-length side rails can increase the risk of injury if the client attempts to climb over them. Half-rails may be safer.
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