Examkin

Soru

Zorluk: KolayBasic Care and Comfort

A nurse is caring for an older adult client who has been diagnosed with dysphagia and is preparing to eat a meal. Which basic care actions should the nurse implement to promote comfort and ensure safety? Select all that apply.

  1. Elevate the head of the bed to 90 degrees before initiating the meal.Cevap
  2. Instruct the client to tilt their chin slightly downward while swallowing.Cevap
  3. Maintain the client in an upright position for at least 30 minutes after eating.Cevap
  4. D
    Position the client flat in a supine position immediately after the meal to promote rest.
  5. E
    Assign the unlicensed assistive personnel (UAP) to feed the client during this initial meal.

Cevap

The correct actions are elevating the head of the bed to 90 degrees, instructing the client to use the chin-tuck method, and maintaining an upright position for at least 30 minutes after the meal.
Safe oral intake for a client with dysphagia relies heavily on proper body alignment. High-Fowler's position (90 degrees) and the chin-tuck maneuver protect the airway anatomically during the meal, while remaining upright for 30 to 45 minutes afterward prevents reflux and delayed aspiration.

Adım Adım Çözüm

1
Identify the primary risks associated with dysphagia.
The main risk is the aspiration of food or fluids into the respiratory tract.
Understanding the risk guides the selection of safe positioning and appropriate feeding techniques.
2
Evaluate each intervention for its effect on swallowing safety.
Upright positioning and the chin-tuck maneuver physically protect the airway.
Gravity and anatomical positioning are the primary non-pharmacologic defenses against aspiration.
3
Determine appropriate delegation for the task.
Initial assessment and feeding of a client with a new dysphagia diagnosis must be performed by the registered nurse.
UAPs cannot perform initial clinical assessments or evaluate swallowing effectiveness.

Anahtar Kavram

Basic care and safety measures for clients with dysphagia primarily involve proper positioning to prevent aspiration and retaining initial nursing assessments rather than delegating them.
Bu soruyu puanla

Konular

Basic Care and Comfort

Bu konudan daha fazla soru