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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Perform CPR on the client:
Performing CPR is a critical intervention during cardiac arrest to maintain circulation and oxygenation. Assistive personnel are trained in basic CPR techniques and can effectively administer chest compressions according to established protocols. Assigning this task to assistive personnel allows the nurse to focus on other aspects of resuscitation and coordination of care.
B) Assist with airway intubation:
Airway intubation requires specialized training and skills, typically performed by licensed healthcare providers such as nurses or physicians. While assistive personnel may assist with preparing equipment or positioning the client, they are not trained to perform airway intubation procedures.
C) Place defibrillator pads on the client:
Placing defibrillator pads requires knowledge of proper positioning and electrode placement to deliver effective defibrillation shocks. This task is typically performed by healthcare providers with training in advanced cardiac life support (ACLS). Assistive personnel may assist with tasks such as preparing the client's chest and clearing the area for defibrillation, but they do not typically apply the pads themselves.
D) Maintain IV access:
Maintaining IV access involves monitoring the IV site, adjusting flow rates, and administering medications or fluids as ordered. While assistive personnel may assist with tasks related to IV access, such as holding the IV bag or adjusting tubing, they are not typically responsible for the overall management and maintenance of IV access during a cardiac arrest situation.
Correct Answer is C
Explanation
A) A nurse tells a client's health care surrogate that the client might require restraints if diversion activities are ineffective:
This scenario does not represent slander. While discussing the possibility of using restraints with a client's health care surrogate involves sensitive communication, it does not constitute slander. The nurse is providing information about potential interventions based on the client's needs and safety concerns, which is a part of the nursing role.
B) A nurse documents that a client was shouting and directly quotes the client's words:
This scenario involves accurate documentation of a client's behavior and does not constitute slander. Documenting a client's actions, such as shouting, with direct quotes from the client's words is essential for providing an accurate record of events and communication during the client's care.
C) A client overhears assistive personnel make a false statement about the assigned nurse and requests a different nurse:
This scenario represents slander. Slander involves making false statements that harm someone's reputation, and in this case, the assistive personnel's false statement about the assigned nurse could damage the nurse's professional reputation. The client's request for a different nurse indicates the potential negative impact of the false statement on the nurse's relationship with the client.
D) A staff member reports to the unit supervisor during a private meeting that a coworker is possibly impaired:
This scenario involves reporting a concern about a coworker's potential impairment, which is not an example of slander. Reporting concerns about impairment is a critical aspect of ensuring patient safety and maintaining professional standards in healthcare settings. However, such reports should be handled confidentially and with appropriate discretion.
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