A nurse is caring for a client who has dysphagia. Which of the following actions should the nurse take?
Place the client in a semi-Fowler's position when eating.
Initiate calorie count of daily food intake.
Instruct the client to keep their chin up when swallowing.
Provide food in a thin liquid consistency.
The Correct Answer is A
Place the client in a semi-Fowler's position when eating. The semi-Fowler's position involves elevating the head of the bed to an angle of 30 to 45 degrees. This position helps prevent aspiration by facilitating proper swallowing and reducing the risk of food or liquid entering the airway.
Initiating a calorie count of daily food intake is not a specific action for dysphagia. Calorie counting is generally used for monitoring caloric intake in clients with specific dietary needs or conditions, but it is not directly related to dysphagia management. The focus for dysphagia management is on ensuring safe swallowing and preventing complications such as aspiration.
Instructing the client to keep their chin up when swallowing is not appropriate for dysphagia management. This action can actually increase the risk of aspiration. The proper technique for swallowing with dysphagia typically involves tucking the chin slightly down towards the chest to help close off the airway and direct the food or liquid down the esophagus.
Providing food in a thin liquid consistency is not appropriate for dysphagia unless specifically recommended by a healthcare professional. Dysphagia diets typically involve modifying the consistency of food and liquids based on the client's swallowing abilities and recommendations from a speech-language pathologist or dietitian. Different levels of texture modifications (such as pureed, minced, or mechanically soft) may be prescribed to ensure safe swallowing and reduce the risk of aspiration.
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Related Questions
Correct Answer is B
Explanation
Phenylketonuria (PKU) is an inherited metabolic disorder in which the body cannot properly process an amino acid called phenylalanine. If left untreated, phenylalanine can build up to harmful levels in the body, leading to intellectual disability and other health problems. Managing PKU involves following a strict low-phenylalanine diet.
When discussing anticipatory guidance for a client with PKU who is planning a pregnancy, it is important to focus on monitoring the maternal phenylalanine levels during pregnancy. Serum bilirubin is not directly related to PKU management and would not require specific monitoring in this context.
Regarding the other options:
"Diet sodas should not be consumed more than two or three times per week": While it is generally advisable to limit the consumption of diet sodas due to their artificial sweeteners, this statement does not directly relate to PKU management or pregnancy planning.
"A low-protein diet should be followed for 3 months prior to conception": A low-protein diet is a fundamental aspect of managing PKU. However, the timeline mentioned (3 months prior to conception) is not supported by current guidelines. PKU management should be ongoing and tailored to the individual's needs, with dietary adjustments made as necessary throughout pregnancy.
"Breastfeeding will prevent your baby from developing PKU": This statement is incorrect. Breast milk naturally contains phenylalanine, which could be harmful to an infant with PKU. Infants with PKU must receive a specialized formula that is low in phenylalanine from birth. Breastfeeding is not recommended for infants with PKU unless specifically guided by a healthcare professional.
Correct Answer is A
Explanation
In type 1 diabetes mellitus, when blood glucose levels are consistently high, the body may start breaking down fat for energy, leading to the production of ketones. Ketones can be detected in urine as a result. A blood glucose level of 190 milligrams per deciliter is elevated and can potentially trigger the production of ketones. Monitoring urine for ketones can be an important indicator of diabetes management and helps identify potential complications.
The other statements by the client indicate a lack of understanding or potential misconceptions:
● "I will keep my blood glucose levels between 200 and 212 milligrams per deciliter": This statement suggests a target range that is higher than the recommended target blood glucose levels for individuals with diabetes. Generally, the target range for blood glucose levels in individuals with diabetes is lower, typically between 80-130 mg/dL before meals and below 180 mg/dL after meals.
● "Albumin in my urine is an indication of normal kidney function": This statement is incorrect. The presence of albumin in the urine, called albuminuria, is an indication of kidney damage or dysfunction. It is a common sign of kidney disease, including diabetic nephropathy, which is a complication of diabetes affecting the kidneys.
● "I will keep my HbA1c at five percent": While maintaining a lower HbA1c level is generally desirable for individuals with diabetes, a target of five percent is too low. HbA1c is a measure of average blood glucose levels over the past two to three months. The American Diabetes Association (ADA) recommends an HbA1c target of less than 7 percent for most adults with diabetes, although individualized targets may vary based on factors such as age and other health conditions.
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