A nurse is reinforcing teaching with a client who has hypertension and a prescription to measure their blood pressure daily. Which of the following client statements indicates an understanding of the teaching?

The correct answer is choice A.

Choice A rationale:

Count the client's radial and apical pulses simultaneously with another nurse. Rationale: In the presence of an irregular heart rate, a pulse deficit might indicate a discrepancy between the peripheral (radial) and central (apical) pulses. Counting the pulses simultaneously with another nurse helps to accurately assess this deficit. By comparing the two pulse rates, the nurse can identify if there is a difference, which might indicate inadequate circulation or irregular heartbeats that aren't effectively transmitting to the peripheral arteries.

Choice B rationale:

Calculate the client's pulse for 30 seconds and multiply by 2. Rationale: While calculating the pulse rate for 30 seconds and then multiplying by 2 is a valid method to determine the heart rate, it doesn't address the specific concern of a pulse deficit. This approach might help in assessing the overall heart rate but doesn't provide information about potential irregularities or discrepancies between peripheral and central pulses.

Choice C rationale:

Assist the client to a side-lying position. Rationale: Assisting the client to a side-lying position doesn't directly relate to the assessment of a pulse deficit. The position of the client wouldn't significantly impact the assessment of irregular heart rates or pulse deficits.

Choice D rationale:

Auscultate the area of the client's chest over the Erb's point. Rationale: Auscultating the area of the client's chest over the Erb's point is a technique used to assess heart sounds, particularly the S2 heart sound. This technique is not relevant to assessing a pulse deficit. It can provide information about heart valve function but doesn't help in evaluating a discrepancy between peripheral and central pulses.

The correct answer is choice D: "Instruct the client to tilt their head forward while eating."

Choice A rationale:

Offering the client a straw to drink liquids might not be suitable for someone with dysphagia following a stroke. Straws can sometimes contribute to aspiration risk, especially if the client has difficulty controlling their swallowing reflex. Using a straw might lead to aspiration of liquids, which can be dangerous for the client's respiratory health.

Choice B rationale:

Placing food toward the back of the client's mouth could increase the risk of choking and aspiration, especially if the client has difficulty swallowing due to dysphagia. It's important to place small bites of food at the front of the mouth and encourage slow, controlled chewing and swallowing to reduce the risk of aspiration.

Choice C rationale:

Encouraging the client to lie down and rest for 30 minutes after meals is not a recommended intervention for someone with dysphagia. This position can actually increase the risk of aspiration. The client should be in an upright position while eating and for some time after eating to allow gravity to assist in preventing aspiration.

Choice D rationale:

Instructing the client to tilt their head forward while eating helps to facilitate safer swallowing by preventing food from entering the airway. This posture helps direct the food toward the esophagus and reduces the risk of aspiration. It's an essential technique for clients with dysphagia to maintain their airway safety while eating.