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 ["A","D","E"]
Explanation
The correct answer is A, D, and E.
Here is why:.
A. “You may experience dizziness when you stand up quickly.” This is true because aging causes the arteries and arterioles to become less elastic and less able to adjust the blood pressure quickly when the posture changes.This can lead to a drop in blood pressure when standing up, which can cause dizziness or fainting.
D. “Your blood vessels may become stiffer and narrower.” This is true because aging causes the walls of the arteries and arterioles to become thicker and stiffer, which reduces their compliance and increases the resistance to blood flow.This can lead to high blood pressure, atherosclerosis, and other cardiovascular diseases.
E. “Your heart may skip some beats or have extra beats.” This is true because aging causes changes in the electrical system of the heart, which can result in arrhythmias such as atrial fibrillation, premature ventricular contractions, or sinus bradycardia.These can cause irregular heartbeats that may be felt as palpitations or skipped beats.
B. “Your blood pressure may drop when you are resting.” This is false because aging does not cause a decrease in blood pressure at rest.
In fact, aging tends to increase the systolic blood pressure (the pressure when the heart contracts) due to the stiffening of the arteries.The diastolic blood pressure (the pressure when the heart relaxes) may remain normal or decrease slightly, resulting in a widened pulse pressure (the difference between systolic and diastolic pressures).
C. “Your heart may beat faster when you exercise.” This is false because aging does not cause an increase in heart rate during exercise.
In fact, aging tends to decrease the maximum heart rate that can be achieved during exercise due to the reduced responsiveness of the heart to adrenergic stimuli.The older heart also takes longer to recover after exercise.
Normal ranges for blood pressure are less than 120/80 mmHg for adults of any age.Normal ranges for heart rate are 60-100 beats per minute for adults of any age, but the maximum heart rate decreases with age according to the formula 220 minus age.
Correct Answer is D
Explanation
The correct answer isD.
Decreased perspiration.This is because the sweat glands become less active with aging, resulting in reduced sweating and dryness of the skin.Decreased perspiration can also affect the body’s ability to regulate its temperature and may cause heat intolerance.
Choice A is wrong becauseincreased skin vascularityis not a normal age-related change in the integumentary system.In fact, the blood vessels in the skin become thinner and less elastic, resulting in decreased perfusion and a paler skin tone.
Choice B is wrong becausedecreased skin fragilityis not a normal age-related change in the integumentary system.On the contrary, the skin becomes thinner, less elastic, and more prone to splitting, cracking, and infections due to reduced collagen and elastin production, decreased mitosis in the epidermis, and lowered immunity.
Choice C is wrong becauseincreased sebaceous gland activityis not a normal age-related change in the integumentary system.Rather, the sebaceous glands produce less sebum, which contributes to the dryness and loss of moisture in the skin.
Normal ranges for some of the parameters related to the integumentary system are:.
• Skin thickness: varies depending on body location, but generally ranges from 0.5 mm to 4 mm.
• Skin elasticity: measured by the Cutometer device, which uses negative pressure to lift the skin and calculate its elasticity.
A higher value indicates more elastic skin.The average elasticity value for young adults is 0.82, while for older adults it is 0.57.
• Skin moisture: measured by the Corneometer device, which uses electrical capacitance to assess the hydration level of the stratum corneum (the outermost layer of the skin).
A higher value indicates more hydrated skin.The average moisture value for young adults is 62.8, while for older adults it is 51.3.
• Perspiration: measured by the Evaporimeter device, which uses a humidity sensor to detect the amount of water vapor lost from the skin surface.
A higher value indicates more perspiration.The average perspiration value for young adults is 13.9 g/m2/h, while for older adults it is 9.8 g/m2/h.
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