A nurse is supervising an assistive personnel who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
Providing a 10 min rest period prior to meals
Elevating the head of the client’s bed to 30 degrees during mealtime
Instructing the client to place her chin toward her chest when swallowing
Withholding fluids until the end of the meal
The Correct Answer is C
a. Providing a 10-minute rest period prior to meals:
This action is not specifically related to feeding technique for clients with dysphagia. While providing a rest period before meals may be beneficial for some clients, especially those who experience fatigue or dyspnea, it is not a standard technique for managing dysphagia during mealtime.
b. Elevating the head of the client’s bed to 30 degrees during mealtime:
The head of the bed should be elevated to at least 45–90 degrees during meals to minimize the risk of aspiration. A 30-degree elevation is insufficient for safe swallowing and increases the likelihood of aspiration.
c. Instructing the client to place her chin toward her chest when swallowing:
This technique, known as the chin-tuck maneuver, helps reduce the risk of aspiration in clients with dysphagia by improving airway protection and directing food and liquid down the esophagus instead of the trachea. It is a widely recommended method to promote safe swallowing.
d. Withholding fluids until the end of the meal:
Fluids should not be withheld until the end of the meal as they are often necessary to help the client swallow food safely and prevent choking. Thickened fluids may be prescribed for clients with dysphagia to aid in safe swallowing.
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Related Questions
Correct Answer is D
Explanation
a. Instruct the client’s family to contact the insurance provider about the oxygen equipment:
This option involves instructing the client's family to take action by contacting the insurance provider. While it may be helpful for the family to be aware of insurance coverage, it does not directly address the immediate issue of the client needing oxygen upon discharge. Additionally, the family may not have the necessary information or authority to resolve the delivery delay.
b. Send an oxygen tank from the facility home with the client:
This option involves providing the client with an oxygen tank from the facility to ensure they have access to oxygen upon discharge. While it may temporarily address the client's immediate need, it may not be feasible or appropriate for the facility to provide oxygen equipment directly without coordinating with the equipment company and following proper protocols.
c. Contact social services about the delivery of the oxygen equipment:
This option involves contacting social services to seek assistance with resolving the delay in oxygen equipment delivery. Social services may be able to intervene and expedite the delivery process or explore alternative solutions to ensure the client's needs are met. Involving social services can be beneficial in navigating complex discharge issues.
d. Notify the provider about the delayed oxygen tank delivery:
It is important to inform the provider about the delay in oxygen equipment delivery so they can be aware of the situation and make any necessary adjustments to the discharge plan or arrange for alternative solutions. The provider may also assist in expediting the delivery or provide additional instructions for managing the situation.
Correct Answer is B
Explanation
A. The client covers electrical cords with a throw rug: This action is unsafe. Placing a throw rug over electrical cords poses a fire hazard and could lead to tripping. Electrical cords should be secured and kept out of walkways to prevent accidents.
B. The client set the water heater to 49 degrees Celsius (120 degrees Fahrenheit): The water heater should be set to a maximum temperature of 49°C (120°F) to prevent scalding injuries, which are a concern for older adults whose skin may be more sensitive. Temperatures higher than this increase the risk of burns.
C. The client has the refrigerator set to 7.2 degrees Celsius (45 degrees Fahrenheit): This temperature is too high. A refrigerator should be set at or below 4°C (40°F) to properly preserve food and prevent bacterial growth. Setting the refrigerator to 7.2°C (45°F) can result in foodborne illnesses.
D. The client has a standard height toilet seat in the bathroom: This may be inadequate for older adults, particularly those with mobility issues. A raised toilet seat may be recommended for better comfort and safety, as it reduces the risk of falls while sitting down or standing up.
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