A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following factors places the client at risk for aspiration?

Sitting in high-Fowler's position during the feeding.

A history of gastroesophageal reflux disease.

A residual of 65 mL 1 hr postprandial.

Receiving a high-osmolarity formula.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Sitting in high-Fowler's position during the feeding is actually a preventive measure against aspiration. High-Fowler's position, which involves sitting the patient upright at a 90-degree angle, reduces the risk of aspiration by promoting proper digestion and preventing the regurgitation of gastric contents into the lungs.

Choice B rationale:

A history of gastroesophageal reflux disease (GERD) puts the client at risk for aspiration. GERD is a chronic condition in which stomach acid frequently flows back into the esophagus, potentially reaching the throat and lungs, increasing the risk of aspiration during enteral feedings. Aspiration pneumonia, a serious complication, can develop if stomach contents enter the lungs.

Choice C rationale:

A residual of 65 mL 1 hr postprandial indicates that a significant amount of the feeding solution has not been absorbed, raising concerns about delayed gastric emptying. While this situation might require monitoring and adjustments to the feeding regimen, it does not directly increase the risk of aspiration. Aspiration risk is more related to the reflux of stomach contents into the airways.

Choice D rationale:

Receiving a high-osmolarity formula alone does not directly increase the risk of aspiration. High-osmolarity formulas might require careful administration and monitoring to prevent complications, but aspiration risk is more closely associated with the client's underlying conditions, such as GERD.

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Correct Answer is D

Explanation

Choice A rationale:

Borderline personality disorder is characterized by impulsivity, unstable relationships, and mood swings. While individuals with this disorder may have concerns about details, it is not the primary characteristic of the disorder. The impulsivity exhibited by these clients is a more prominent feature.

Choice B rationale:

While individuals with borderline personality disorder may struggle with interpersonal relationships and may sometimes display seductive behavior, this is not a defining characteristic of the disorder. The primary concern lies in their impulsivity and emotional instability.

Choice C rationale:

Clinginess can be a feature of borderline personality disorder, but it is not the defining characteristic. The disorder is more accurately characterized by a pervasive pattern of instability in interpersonal relationships, self-image, and affects, marked impulsivity that begins by early adulthood and is present in various contexts.

Choice D rationale:

Borderline personality disorder is indeed marked by impulsive behavior, one of the key diagnostic criteria according to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition). This impulsivity often leads to self-damaging behaviors, such as reckless driving, substance abuse, and unsafe sex. Including this information in the in-service is crucial for an accurate understanding of the disorder.

A. "We should establish our roles in the initial session." B. "Let me show you simple relaxation exercises to manage stress." C. "Let's talk about how you can change your response to stress." D. "We should discuss resources to implement in your daily life." .

Correct Answer is A

Explanation

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A nurse is caring for a client who is receiving intermittent enteral tube feedings.
Which of the following factors places the client at risk for aspiration?