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?

Administer liquids to the client using a syringe.

Elevate the head of the client's bed to 45° during meals.

Instruct the client to tilt their head back when swallowing.

Request a speech therapist consult from the provider.

Answer and Explanation

The Correct Answer is D

A) Administer liquids to the client using a syringe:

Administering liquids using a syringe may not address the underlying issue of food pocketing in the client's cheeks during meals. While syringe feeding may be necessary for clients with severe dysphagia, it does not address the need for comprehensive evaluation and intervention by a speech therapist.

B) Elevate the head of the client's bed to 45° during meals:

Elevating the head of the bed during meals is a standard intervention to help prevent aspiration in clients with dysphagia. While this intervention may be appropriate, it may not directly address the issue of food pocketing in the client's cheeks. Therefore, it is not the most comprehensive intervention for this specific problem.

C) Instruct the client to tilt their head back when swallowing:

Tilting the head back when swallowing is not a recommended intervention for clients with dysphagia. In fact, this maneuver can increase the risk of aspiration, as it can cause food or liquid to enter the airway. Therefore, this intervention would not be appropriate and could potentially exacerbate the client's swallowing difficulties.

D) Request a speech therapist consult from the provider:

This is the most appropriate intervention for addressing the client's dysphagia and food pocketing. Speech therapists are trained to assess and treat swallowing disorders, including pocketing of food in the cheeks. They can conduct a comprehensive evaluation of the client's swallowing function and develop individualized interventions to address the underlying causes of dysphagia. Therefore, requesting a speech therapist consult is the most effective way to manage this issue and improve the client's swallowing safety and efficiency.

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Correct Answer is B

Explanation

A) Examine personal values:

While examining personal values is important in ethical decision-making, it is not the first step in addressing this particular ethical dilemma. Understanding personal values comes after gathering relevant facts and understanding the situation fully.

B) Collect the relevant facts:

This is the most appropriate initial step when facing an ethical dilemma. Gathering relevant information about the child's condition, the prescribed treatment, and the reasons for the parents' refusal is crucial for making informed decisions and developing a plan of action.

C) Create a plan of action:

Creating a plan of action is an important step in addressing the ethical dilemma, but it should come after collecting all relevant facts. Without a clear understanding of the situation, any plan of action may be incomplete or ineffective.

D) Agree on a desired outcome:

While determining a desired outcome is essential, it should be based on a thorough understanding of the situation, which comes from collecting relevant facts. Agreeing on an outcome before fully assessing the situation may lead to premature or uninformed decisions.

A. "I will attempt to extinguish the fire before calling the fire department." B. "I should change the batteries in my smoke alarms every 2 years." C. “I should spray the extinguisher from side to side on the fire." D. "I will use a Class A extinguisher for an electrical fire."

Correct Answer is C

Explanation

A) "I will attempt to extinguish the fire before calling the fire department.": This statement indicates a misunderstanding of fire safety principles. It's crucial for individuals to prioritize their safety and evacuate the premises immediately in the event of a fire. Attempting to extinguish the fire before calling the fire department can waste valuable time and put the individual at risk.

B) "I should change the batteries in my smoke alarms every 2 years.": While changing smoke alarm batteries regularly is essential for ensuring they function properly, the recommended interval for battery replacement is typically every 6 months, not every 2 years. This statement reflects a misunderstanding of the recommended maintenance schedule for smoke alarms.

C) “I should spray the extinguisher from side to side on the fire.": This statement demonstrates an understanding of proper fire extinguisher use. When using a fire extinguisher, it's essential to aim the extinguisher nozzle at the base of the fire and sweep it from side to side until the fire is extinguished. This technique helps to smother the flames effectively and prevent re-ignition.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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