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Questions and Answers
A nurse is preparing to assist a client with dysphagia during mealtime. Which intervention is most important to implement before the meal?
A nurse is preparing to assist a client with dysphagia during mealtime. Which intervention is most important to implement before the meal?
- Offer a choice of dessert.
- Provide a liquid supplement.
- Ensure the client is fully rested. (correct)
- Administer prescribed pain medication.
A client with advanced dementia is having difficulty eating. Which of the following strategies is most appropriate to enhance their nutritional intake?
A client with advanced dementia is having difficulty eating. Which of the following strategies is most appropriate to enhance their nutritional intake?
- Serving the meal in a dimly lit, quiet room to minimize distractions.
- Providing a large tray with a variety of food options.
- Discussing current events to stimulate cognitive function during the meal.
- Offering foods that can be eaten without utensils. (correct)
When assisting a client with unilateral weakness after a stroke, which action promotes safe swallowing?
When assisting a client with unilateral weakness after a stroke, which action promotes safe swallowing?
- Encouraging the client to talk while eating to maintain alertness.
- Placing food on the unaffected side of the mouth. (correct)
- Tilting the client's head back while swallowing.
- Offering large bites of food to stimulate swallowing.
A client with visual impairment is having difficulty locating food items on their plate. Which nursing intervention promotes dietary intake?
A client with visual impairment is having difficulty locating food items on their plate. Which nursing intervention promotes dietary intake?
A nurse is caring for a client with a history of aspiration pneumonia. Which food consistency is most appropriate for this client?
A nurse is caring for a client with a history of aspiration pneumonia. Which food consistency is most appropriate for this client?
A client who is being fed is coughing frequently during meals. What is the priority nursing intervention?
A client who is being fed is coughing frequently during meals. What is the priority nursing intervention?
A nurse is preparing to feed a client who has weakness on their right side. Which intervention will best support the client's independence during the meal?
A nurse is preparing to feed a client who has weakness on their right side. Which intervention will best support the client's independence during the meal?
The assistive personnel (AP) is assisting a client with eating. What observation should the nurse instruct the AP to report immediately?
The assistive personnel (AP) is assisting a client with eating. What observation should the nurse instruct the AP to report immediately?
A nurse is caring for a client with a decreased level of consciousness. What is the most important safety precaution related to feeding?
A nurse is caring for a client with a decreased level of consciousness. What is the most important safety precaution related to feeding?
A client with a new diagnosis of dysphagia is being discharged. Which instruction is most important for the nurse to provide to the client and family?
A client with a new diagnosis of dysphagia is being discharged. Which instruction is most important for the nurse to provide to the client and family?
A nurse observes an assistive personnel (AP) preparing to assist a client with a meal. Which action by the AP requires immediate intervention by the nurse?
A nurse observes an assistive personnel (AP) preparing to assist a client with a meal. Which action by the AP requires immediate intervention by the nurse?
A client is refusing to eat, stating they have no appetite. Which nursing intervention is most appropriate initially?
A client is refusing to eat, stating they have no appetite. Which nursing intervention is most appropriate initially?
A nurse is caring for a client with arthritis who has difficulty using standard eating utensils. Which assistive device is most beneficial?
A nurse is caring for a client with arthritis who has difficulty using standard eating utensils. Which assistive device is most beneficial?
After a meal, a client with dysphagia has a persistent cough and a wet, gurgly voice. What is the nurse's priority action?
After a meal, a client with dysphagia has a persistent cough and a wet, gurgly voice. What is the nurse's priority action?
A nurse is preparing to assist a client with feeding. Which action should the nurse take first?
A nurse is preparing to assist a client with feeding. Which action should the nurse take first?
A client with dementia is easily distracted during meal times. Which environmental modification will promote adequate nutritional intake?
A client with dementia is easily distracted during meal times. Which environmental modification will promote adequate nutritional intake?
Which nursing intervention is most effective in promoting a client's appetite?
Which nursing intervention is most effective in promoting a client's appetite?
A client is receiving pureed foods due to dysphagia. What is an important consideration when serving pureed meals?
A client is receiving pureed foods due to dysphagia. What is an important consideration when serving pureed meals?
A client reports difficulty swallowing pills. Which intervention is most appropriate?
A client reports difficulty swallowing pills. Which intervention is most appropriate?
A client with a history of stroke is having difficulty swallowing liquids. What is the most appropriate intervention to prevent aspiration?
A client with a history of stroke is having difficulty swallowing liquids. What is the most appropriate intervention to prevent aspiration?
A nurse is documenting a client's food intake. Which information is most important to include?
A nurse is documenting a client's food intake. Which information is most important to include?
A client with Parkinson's disease is experiencing tremors that make it difficult to eat. Which utensil modification assistive device is most appropriate?
A client with Parkinson's disease is experiencing tremors that make it difficult to eat. Which utensil modification assistive device is most appropriate?
A client reports a metallic taste in their mouth while eating. Which intervention should the nurse implement?
A client reports a metallic taste in their mouth while eating. Which intervention should the nurse implement?
A client is on a sodium-restricted diet. Which food item should the nurse instruct the client to avoid?
A client is on a sodium-restricted diet. Which food item should the nurse instruct the client to avoid?
A nurse is caring for a client who is at risk for aspiration. Which action is most important to include in the client's plan of care?
A nurse is caring for a client who is at risk for aspiration. Which action is most important to include in the client's plan of care?
Which action by the nurse demonstrates respect for a client's cultural preferences during mealtime?
Which action by the nurse demonstrates respect for a client's cultural preferences during mealtime?
A client with end-stage renal disease is on a fluid restriction. Which intervention is most important to include in the client's plan of care regarding meals?
A client with end-stage renal disease is on a fluid restriction. Which intervention is most important to include in the client's plan of care regarding meals?
Which action minimizes the risk of foodborne illness when assisting clients with meals?
Which action minimizes the risk of foodborne illness when assisting clients with meals?
A client with mucositis (inflammation of the mucous membrane) due to chemotherapy is having difficulty eating. Which food choice is most suitable?
A client with mucositis (inflammation of the mucous membrane) due to chemotherapy is having difficulty eating. Which food choice is most suitable?
A nurse is preparing to administer an oral medication to a client with dysphagia. Which action is most appropriate?
A nurse is preparing to administer an oral medication to a client with dysphagia. Which action is most appropriate?
A client who is postoperative is complaining of nausea and has a poor appetite. Which intervention is most helpful in improving the client's nutritional intake?
A client who is postoperative is complaining of nausea and has a poor appetite. Which intervention is most helpful in improving the client's nutritional intake?
A client with diabetes mellitus requires assistance with meal planning. Which dietary guideline is most important for the nurse to emphasize?
A client with diabetes mellitus requires assistance with meal planning. Which dietary guideline is most important for the nurse to emphasize?
A client is receiving total parenteral nutrition (TPN). What is the priority nursing assessment related to this form of nutrition?
A client is receiving total parenteral nutrition (TPN). What is the priority nursing assessment related to this form of nutrition?
Before assisting a client with feeding, a nurse reviews the client's chart and notes an allergy to shellfish. Which action should the nurse take?
Before assisting a client with feeding, a nurse reviews the client's chart and notes an allergy to shellfish. Which action should the nurse take?
A nursing assistant is preparing to assist a client with feeding. Which action requires the nurse to intervene?
A nursing assistant is preparing to assist a client with feeding. Which action requires the nurse to intervene?
A nurse is caring for a client with dysphagia who is on thickened liquids. Which observation indicates that the client is tolerating the diet?
A nurse is caring for a client with dysphagia who is on thickened liquids. Which observation indicates that the client is tolerating the diet?
Which communication strategy is most appropriate when assisting a client with cognitive impairment during mealtime?
Which communication strategy is most appropriate when assisting a client with cognitive impairment during mealtime?
A client with a tremor is having difficulty feeding themselves. Which of the following interventions is most appropriate to promote independence?
A client with a tremor is having difficulty feeding themselves. Which of the following interventions is most appropriate to promote independence?
The nurse is assisting a client who has cognitive impairment with feeding. Which strategy would be most effective in encouraging the client to eat?
The nurse is assisting a client who has cognitive impairment with feeding. Which strategy would be most effective in encouraging the client to eat?
A nurse is caring for a client who is experiencing anorexia. Which of the following actions is most important to implement?
A nurse is caring for a client who is experiencing anorexia. Which of the following actions is most important to implement?
A client coughs and clears their throat several times after taking a sip of water during mealtime. What is the priority nursing action?
A client coughs and clears their throat several times after taking a sip of water during mealtime. What is the priority nursing action?
The nurse is preparing to assist a client with feeding who has visual impairment. Which intervention is most appropriate?
The nurse is preparing to assist a client with feeding who has visual impairment. Which intervention is most appropriate?
Flashcards
Check for Allergies
Check for Allergies
Determining allergies helps prevent allergic reactions.
Verify Client ID
Verify Client ID
Ensuring you have the correct patient before intervention.
Use Standard Precautions
Use Standard Precautions
Using precautions during contact prevents transmission of infectious organisms.
Assess Consciousness and Swallowing
Assess Consciousness and Swallowing
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Review Medical Record
Review Medical Record
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Provide Privacy
Provide Privacy
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Introduce Yourself
Introduce Yourself
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Provide Client Education
Provide Client Education
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Assess Preferences and Dietary Needs
Assess Preferences and Dietary Needs
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Clear Bedside Environment
Clear Bedside Environment
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Assist to Upright Position
Assist to Upright Position
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Place Protective Covering
Place Protective Covering
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Verify Food Temperatures
Verify Food Temperatures
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Place Food Tray in View
Place Food Tray in View
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Encourage Self-Feeding
Encourage Self-Feeding
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Provide Small Bites
Provide Small Bites
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Observe Swallowing Ability
Observe Swallowing Ability
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Provide Oral Care
Provide Oral Care
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Ensure Client Comfort
Ensure Client Comfort
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Discuss Findings
Discuss Findings
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Ensure Client Safety
Ensure Client Safety
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Assistive Devices
Assistive Devices
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Altered Cognition
Altered Cognition
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Concurrent Medical Conditions
Concurrent Medical Conditions
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Interventions for Unexpected Outcomes
Interventions for Unexpected Outcomes
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Allied Health Consults
Allied Health Consults
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Documentation
Documentation
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Define Dysphagia
Define Dysphagia
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Study Notes
- Clients might need help with eating, ranging from food presentation to full assistance.
- Tailor assistance to individual needs, promoting independence while ensuring optimal nutrition and calorie intake.
- RNs can delegate assisting clients with eating to PNs or APs familiar with aspiration precautions.
Safety Considerations
- Determine if the client has food allergies to prevent allergic reactions.
- Always verify client identification to perform the correct procedure on the correct client.
- Use standard precautions to prevent transmission of infectious organisms.
- Assess the client’s consciousness, orientation, and physical impairments to prevent nutritional deficits, weight loss, aspiration, and choking.
Equipment
- Nonsterile gloves and PPE (if indicated) are needed.
- Prepared food and liquids should match dietary needs and preferences.
- Use a protective covering like a towel prevent soiling the client's clothes.
- Napkins or washcloths are needed for client cleanliness.
- Adaptive devices like glasses, hearing aids, dentures, and utensils can improve the client's experience.
- Oral care items are needed to provide oral care after meals, promoting comfort and preventing infection.
Step-by-Step Guide
- Step 1: Review the client’s medical record for allergies, medical history, medications, vital signs, and lab values.
- Step 2: Gather necessary supplies.
- Step 3: Provide privacy to maintain confidentiality.
- Step 4: Introduce yourself, fostering a therapeutic relationship.
- Step 5: Hand hygiene and PPE prevent infection.
- Step 6: Use two identifiers to confirm the client’s identity.
- Step 7: Confirm the client’s allergy status to prevent allergic reactions.
- Step 8: Educate the client to alleviate anxiety and foster trust.
- Step 9: Assess level of consciousness, hearing/visual acuity, swallowing ability, and motor skills.
- Step 10: Consider cultural, religious, and food preferences.
- Step 11: Clear the bedside of unpleasant items and odors to stimulate appetite.
- Step 12: Position the client upright to prevent aspiration.
- Step 13: Use a protective covering to prevent clothing from becoming soiled.
- Step 14: Verify the food tray matches the prescribed diet and has appropriate temperatures.
- Step 15: Present the food tray to the client to encourage participation.
- Step 16: Ask about food preferences, cut food as needed, and ensure items are within reach to enable independence.
- Step 17: Sit at eye level to socialize and assess the client.
- Step 18: Encourage self-feeding to promote dignity and maintain function.
- Step 19: Offer small bites, allow time to chew, and provide drinks for dysphagia and energy preservation.
- Step 20: Observe the client’s ability to swallow to prevent aspiration.
- Step 21: Clear the tray and note the amount of food consumed.
- Step 22: Offer oral care to prevent breakdown, caries, and infection.
- Step 23: Reposition, assist with hand hygiene, and offer toileting assistance to promote comfort.
- Step 24: Assist the client to a comfortable position.
- Step 25: Discuss findings to reduce anxiety and promote engagement.
- Step 26: Ensure client safety before leaving the room by placing needed items within reach.
Client Considerations
- Clients with physical alterations may need adaptive devices.
- Clients with dysphagia are at risk of choking, aspiration, hypoxia, or pulmonary infection.
- Clients with dementia or altered cognition may need assistance with eating.
- Clients with concurrent conditions or nausea may need attention to preferences and environment.
Interventions for Unexpected Outcomes
- For physical alterations, request therapy and nutrition consults for swallowing evaluation, assistive devices, and dietary modifications.
- For visual impairment, use a clock pattern to describe the meal’s layout.
- For dementia or altered cognition, prepare food in front of the client and maintain a mealtime routine.
- Supervise meals, respond to cues, and ensure sensory aids are in use.
- Offer finger foods, small meals, and one food at a time; stroke the throat to promote swallowing.
- For dysphagia, discourage talking, ensure rest, position upright, and minimize distractions.
- Offer food at the client’s pace, alternate solids and liquids, and assess medications.
- Always provide oral care and request allied health consults.
- Create a pleasant, calm environment to reduce confusion, sensory issues, and fatigue.
- Sedatives and hypnotics may impair the gag reflex, increasing aspiration risk.
- Stroke the client’s throat to promote swallowing.
- Alternating liquids and solids helps to clear the mouth prior to taking in more food, and reminding the client to avoid talking while chewing or swallowing prevents choking and aspiration.
Documentation
- Document assessments, interventions, position, percentage eaten, swallowing issues, and any interventions.
- Accurate documentation ensures data access for the healthcare team.
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