A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

Ask the client to tilt their head back when swallowing.

Have the client sit upright for 1 hr following meals.

Administer liquids to the client using a syringe.

Allow the client to rest for 10 min prior to eating.

Answer and Explanation

The Correct Answer is B

A. Ask the client to tilt their head back when swallowing. Tilting the head back increases the risk of aspiration by opening the airway. Instead, the "chin tuck" method is recommended.

B. Have the client sit upright for 1 hr following meals. Sitting upright for an extended period reduces the risk of aspiration by allowing gravity to assist in digestion.

C. Administer liquids to the client using a syringe. Using a syringe can increase the risk of aspiration and does not allow the client to control swallowing.

D. Allow the client to rest for 10 min prior to eating. While rest may help conserve energy, it is not a priority intervention for dysphagia management.

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Correct Answer is D

Explanation

A. The client reports taking the medication 30 min before the prescribed time. Taking a medication slightly earlier is unlikely to significantly affect its therapeutic efficacy.

B. The client received an influenza vaccine 1 month ago. Vaccination does not interfere with arthritis medications unless it triggers an immune response leading to disease flare-up, which is rare.

C. The client reports taking the medication with room temperature water. The temperature of the water does not impact the drug’s effectiveness.

D. The client has a history of recurring bowel inflammation. Chronic bowel inflammation (e.g., Crohn’s disease) can affect drug absorption, reducing medication effectiveness.

A. Place the client on their side with their head forward. B. Administer an anticonvulsant medication. C. Time the length of the client's seizure. D. Loosen the client's gown and allow them to move freely.

Correct Answer is A

Explanation

A. Place the client on their side with their head forward. This position helps maintain an open airway, prevents aspiration, and allows secretions to drain. It is the priority intervention during an active seizure.

B. Administer an anticonvulsant medication. Medications like benzodiazepines (e.g., lorazepam) are used to stop prolonged seizures but are not the immediate priority over airway protection.

C. Time the length of the client's seizure. While monitoring seizure duration is important, ensuring airway protection and safety comes first.

D. Loosen the client's gown and allow them to move freely. While restrictive clothing should be loosened, allowing unrestricted movement could lead to self-injury.

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A nurse is updating a plan of care after an evaluation of a client who has dysphagia. Which of the following interventions should the nurse Include In the plan?

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Naxlex Comprehensive Predictor Exams

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