A nurse is supervising assistive personnel (AP) 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 10min 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

Answer and Explanation

The Correct Answer is B

a.   Providing a rest period prior to meals may be appropriate for some clients, but 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 helps prevent aspiration and facilitates swallowing in clients with dysphagia.
c.   Instructing the client to place her chin toward her chest when swallowing is not recommended and may increase the risk of aspiration.
d.   Withholding fluids until the end of the meal is not recommended for clients with dysphagia, as they may need fluids to help with swallowing and to prevent dehydration.

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Correct Answer is A

Explanation

a. Before taking any further action, the charge nurse should first determine the reasons why the nurses are not taking their scheduled breaks. Understanding the underlying causes will help address the issue effectively.
b. Providing coverage for the nurses' breaks may be necessary but should not be the first action taken. It is important to understand why the nurses are not taking breaks before providing coverage.
c. While reviewing facility policies is important, it should not be the first step when addressing the issue of nurses not taking breaks.
d. Discussing time management strategies with the nurses may be helpful, but it should come after understanding the reasons behind their behavior.

A. Ask the client's son to go to the waiting area B. File an incident report C. Treat and discharge the client D. Ask the client about his injuries with the son present

Correct Answer is A

Explanation

1. A. Asking the client's son to go to the waiting area is the appropriate first step if elder abuse is suspected. It allows the nurse to speak with the client privately, which can help the client feel more secure and be more open about discussing sensitive issues such as abuse without fear of retaliation or immediate consequences.
  
  B. Filing an incident report is an important step in documenting suspected abuse, but it should not be the first action taken. Documentation should occur after an initial assessment and gathering of information that supports the suspicion of abuse.
  
  C. Treating and discharging the client may address the immediate physical health needs but does not address the potential safety concerns or the suspicion of abuse. Discharging the client back into a potentially harmful environment without further assessment or intervention could place the client at risk of further harm.
  
  D. Asking the client about his injuries with the son present is not advisable if abuse is suspected. The presence of the potential abuser can influence the client's responses and may prevent the client from disclosing abuse due to fear or intimidation.

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A nurse is supervising assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?

Nursing Test Bank

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A nurse is supervising assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?