A nurse is caring for a client who has oral achalasia. The nurse should ask the client which of the following questions to assess their ability to swallow?
"Do you feel like you have food stuck at the base of your throat?"
"Do you feel any burning sensations in your throat?"
"Do you have any feelings of fullness in the neck?"
"Do you have any problems with pain while swallowing?"
The Correct Answer is A
Choice A reason: Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.
Choice B reason: While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.
Choice C reason: Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.
Choice D reason: Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Administering prescribed corticosteroids is not the appropriate action for dyspnea associated with fluid overload from IV infusion. Corticosteroids are typically used to manage inflammatory conditions and are not indicated for this scenario.
Choice B reason: Slowing the infusion rate is the correct action when signs of fluid overload are present, such as dyspnea and hypertension. This helps to prevent further fluid accumulation. Contacting the provider is essential for further evaluation and management, which may include adjusting the fluid regimen or prescribing diuretics to manage the fluid overload.
Choice C reason: Lowering the head of the bed to a semi-Fowler's position may provide temporary relief for dyspnea but does not address the underlying issue of fluid overload. It is a supportive measure but should be accompanied by other interventions to manage the client's condition.
Choice D reason: Changing the infusion to lactated Ringer's would not address the issue of fluid overload and could potentially exacerbate the situation if the rate is maintained. The type of IV fluid is less important than the volume and rate of administration in the case of fluid overload.
Correct Answer is B
Explanation
Choice A reason: Papilledema, which is the swelling of the optic disc due to increased ICP, is not typically an early sign. It is usually a later manifestation because it takes time for the pressure to build up and affect the optic nerve.
Choice B reason: Restlessness can be an early sign of increased ICP. As ICP begins to rise, it can cause subtle changes in a person's level of consciousness, leading to agitation or restlessness. This is often one of the first signs that healthcare providers notice when monitoring for changes in neurological status.
Choice C reason: Projectile vomiting may occur with increased ICP, but it is not usually an early sign. It tends to occur after other symptoms such as headache and altered consciousness and is more indicative of significant pressure increases that affect the brainstem.
Choice D reason: Decorticate posturing is a severe sign of brain injury associated with increased ICP but is not an early sign. It indicates significant damage to the brain and is a late and ominous sign in the progression of increased ICP.
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