A nurse is caring for a client who has dysphagia due to decreased esophageal motility.
Which of the following actions should the nurse take?
Encourage the client to drink thin liquids.
Instruct the client to tuck their chin when swallowing.
Offer the client foods that are hot or spicy.
Elevate the head of the bed to 30 degrees during meals.
The Correct Answer is B
The correct answer is B.
Instruct the client to tuck their chin when swallowing.
This action helps to prevent aspiration by closing off the airway and directing food and liquid into the esophagus. It also reduces the risk of food getting stuck in the throat or chest .
Choice A is wrong because thin liquids are more difficult to swallow and control for clients who have dysphagia due to decreased esophageal motility. They can easily enter the airway and cause choking or pneumonia .
Choice C is wrong because hot or spicy foods can irritate the esophagus and worsen the symptoms of dysphagia. They can also trigger reflux, which can damage the esophageal lining and cause narrowing or inflammation .
Choice D is wrong because elevating the head of the bed to 30 degrees during meals is not enough to prevent aspiration or regurgitation. The client should be sitting upright at 90 degrees or higher to facilitate swallowing and gravity .
Normal ranges for esophageal motility are:.
• Lower esophageal sphincter pressure: 10 to 45 mm Hg.
• Peristaltic amplitude: 30 to 180 mm Hg.
• Peristaltic duration: 2.5 to 6 seconds.
• Peristaltic velocity: 2 to 4.5 cm/s .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
“You should apply moisturizer to your skin after bathing.” This statement is based on the fact that dry skin is a common problem among older adults, especially in cold or dry weather.Applying moisturizer after bathing can help to lock in the moisture and prevent further water loss from the skin.
Choice A is wrong because drinking more water may not be enough to hydrate the skin if the skin barrier is impaired or damaged.Drinking water is important for overall health, but it does not directly affect the moisture content of the skin.
Choice B is wrong because avoiding soap and hot water when bathing may not be sufficient to prevent dry skin.
Soap can strip the natural oils from the skin, but so can hot water.It is recommended to use mild, non-soap cleansers and warm water instead of hot water when bathing.
Choice C is wrong because wearing layers of clothing to keep warm may not address the underlying cause of feeling cold.Older adults may feel cold more than usual due to various factors, such as thinning of the skin, decreased blood circulation, reduced muscle mass, or hormonal changes.
Wearing layers of clothing may help to maintain body temperature, but it does not treat the cause of feeling cold.
Normal ranges for skin moisture and body temperature vary depending on individual factors, such as age, health status, environment, and activity level.
However, some general guidelines are:.
• Skin moisture: The skin should feel soft and smooth, not rough or scaly.
The skin should not have cracks, flakes, or redness.The skin should have a normal color, not pale or grayish.
• Body temperature: The normal body temperature for adults is around 98.6°F (37°C), but it can vary slightly depending on the time of day, activity level, and other factors.A body temperature below 95°F (35°C) is considered hypothermia and requires immediate medical attention.
Correct Answer is B
Explanation
The correct answer is B. Decreased stroke volume.
Stroke volume is the amount of blood pumped by the left ventricle of the heart in one contraction.
The contractile strength of the myocardium determines how much blood is ejected with each beat.As people age, the myocardium becomes less elastic and less responsive to catecholamines, which can reduce the contractile force and lower the stroke volume.
Choice A is wrong because increased heart rate is not related to the decreased contractile strength of the myocardium, but rather to the decreased responsiveness of the baroreceptors, which regulate blood pressure.Older adults may have higher resting heart rates and lower maximum heart rates than younger adults.
Choice C is wrong because increased cardiac output is not related to the decreased contractile strength of the myocardium, but rather to the increased blood volume and cardiac workload that may occur with aging.Cardiac output is the product of stroke volume and heart rate, so a lower stroke volume would tend to decrease cardiac output.
Choice D is wrong because decreased peripheral resistance is not related to the decreased contractile strength of the myocardium, but rather to the decreased elasticity and increased stiffness of the arterial walls that may occur with aging.
Peripheral resistance is the opposition to blood flow caused by friction between the blood and the vessel walls.A higher peripheral resistance would increase the afterload on the heart and reduce the stroke volume.
Normal ranges for stroke volume are 60 to 100 mL/beat for men and 50 to 90 mL/beat for women.
Normal ranges for heart rate are 60 to 100 beats per minute for adults.
Normal ranges for cardiac output are 4 to 8 L/min for adults.
Normal ranges for peripheral resistance are 800 to 1200 dynes/sec/cm-for adults.
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