A nurse is caring for an older adult client.

Exhibits

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

A. Tucking the chin toward the chest (not lifting the chin) may help improve swallowing by narrowing the airway, making it easier to swallow and reducing the risk of aspiration.
B.This positioning makes it easier for the nurse to observe signs of dysphagia, offer assistance as needed, and maintain better eye contact with the client. It also helps promote a more relaxed and reassuring environment, which can improve the client’s ability to swallow.
C. Talking during feeding can increase the risk of aspiration and compromise safe swallowing.
D. Coughing during feedings should not be discouraged, as it may indicate that the client is attempting to clear the airway and should be monitored carefully.

The client is at risk for developing transient tachypnea of the newborn andhypoglycemia.

Rationale

Target 1: Transient Tachypnea of the Newborn (TTN)

• Transient tachypnea of the newborn (TTN) is a condition characterized by rapid breathing (tachypnea) in the first few hours after birth, typically caused by delayed clearance of fetal lung fluid. It often resolves within 24-48 hours.
• The newborn in the exhibit has a respiratory rate that is increasing: at 64 minutes, the rate is 68/min, and it increases to 76/min by 0700. This is significantly higher than the normal respiratory rate for a newborn (30-60/min) and is a key sign of tachypnea.
• Given the increased respiratory rate and the newborn’s age, transient tachypnea of the newborn is a likely concern. This condition is particularly common in late preterm and full-term infants who experience some delay in clearing fetal lung fluid after birth.

Target 2: Hypoglycemia

• Hypoglycemia in newborns can occur due to several factors, such as increased metabolic demand (which could be indicated by the tachycardia and respiratory rate), poor feeding, or stress during delivery.
• Tachycardia is one of the early signs of hypoglycemia in newborns, as the body responds to low blood sugar by increasing the heart rate to compensate for the lack of energy.
• The heart rate is consistently high, with values of 154/min and 156/min during the assessment. This tachycardia could be indicative of hypoglycemia, as the body works harder to compensate for low glucose levels.

Rationale for other conditions;

Bronchopulmonary Syndrome:

This condition refers to lung diseases like bronchopulmonary dysplasia (BPD), which typically occurs in premature infants who have had prolonged mechanical ventilation. There are no signs of this condition in the current assessment, such as the need for respiratory support or signs of chronic lung disease.

The newborn's respiratory rate and tachycardia are more consistent with transient tachypnea rather than a chronic condition like bronchopulmonary syndrome.

Tachycardia:

Tachycardia itself is a symptom, not a diagnosis. The infant's tachycardia could be a response to hypoxia or hypoglycemia, so the condition causing the tachycardia needs to be addressed (which is hypoglycemia and transient tachypnea of the newborn).