A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
Pneumonia
Pressure injury
Pulmonary embolism
Diarrhea
The Correct Answer is A
A. Pneumonia:
Dysphagia, or difficulty swallowing, can lead to aspiration, where food or liquids enter the airway and lungs instead of the stomach. This can result in pneumonia, an infection of the lungs. Clients with dysphagia are at an increased risk of developing pneumonia due to the aspiration of foreign material into the lungs.
B. Pressure Injury:
Pressure injuries (formerly known as pressure ulcers or bedsores) are caused by prolonged pressure on the skin, usually over bony prominences. Dysphagia itself is not directly related to pressure injuries. These injuries are more commonly associated with immobility and constant pressure on specific areas of the body.
C. Pulmonary Embolism:
Pulmonary embolism is a blockage of the pulmonary artery, usually by a blood clot that travels to the lungs from the legs or other parts of the body. While dysphagia is not directly associated with pulmonary embolism, conditions that cause immobility (such as being bedridden due to dysphagia) can contribute to the risk of developing blood clots.
D. Diarrhea:
Dysphagia is difficulty swallowing and is not directly related to diarrhea. Diarrhea is often associated with gastrointestinal issues, infections, or dietary factors. Monitoring for complications of dysphagia would primarily focus on respiratory issues, such as aspiration pneumonia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
This is a correct action. Cleaning the wound with a sterile solution, such as 0.9% sodium chloride, helps minimize contamination and ensures a more accurate culture.
B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
Using antiseptics directly on the wound before obtaining a specimen can interfere with the culture results. It's essential to use a non-bacteriostatic solution for cleaning.
C. Include intact skin at the wound edges in the culture.
The culture should focus on the material within the wound itself rather than including intact skin. The goal is to identify the specific pathogens causing the infection.
D. Swab an area of skin away from the wound to identify normal flora.
The specimen should be taken directly from the wound site to identify the pathogens responsible for the infection. Swabbing away from the wound won't provide relevant information.
Correct Answer is D
Explanation
A. Diminished reflexes:
Explanation: Diminished reflexes are not typically associated with hypoglycemia. Instead, hypoglycemia may cause hyperactive reflexes or tremors.
B. Rapid respirations:
Explanation: Rapid respirations are not a common manifestation of hypoglycemia. In hypoglycemia, the body might respond with shallow, rapid breathing or hyperventilation.
C. Acetone breath:
Explanation: Acetone breath, often described as fruity or sweet, is associated with diabetic ketoacidosis (DKA), which is a complication of hyperglycemia rather than hypoglycemia.
D. Headache:
Explanation: Headache is a common manifestation of hypoglycemia. It can occur as a result of decreased glucose levels affecting the brain.
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