A nurse is caring for a client who has dysphagia.
Which of the following actions should the nurse take?

Choice A rationale

Placing the client in a prone position is contraindicated during nasogastric tube insertion. This position does not facilitate the passage of the tube into the esophagus and can increase the risk of aspiration if the client were to vomit. The optimal position is high Fowler's, which utilizes gravity to aid tube advancement.

Choice B rationale

Measuring the nasogastric tube from the tip of the nose to the earlobe to the xiphoid process is the correct technique to estimate the length of the tube needed to reach the stomach. This method accounts for the distance from the nasal passage, down the pharynx and esophagus, to the stomach.

Choice C rationale

Instructing the client to place their chin to their chest and swallow helps to close the epiglottis, thereby preventing the nasogastric tube from entering the trachea and directing it towards the esophagus. Swallowing facilitates the downward movement of the tube with esophageal peristalsis.

Choice D rationale

Advancing the nasogastric tube quickly increases the client's discomfort and anxiety and elevates the risk of trauma to the nasal passages, pharynx, and esophagus. The tube should be advanced slowly and gently, allowing the client to swallow and cooperate during the procedure.

Choice A rationale

Increased hair growth is typically associated with hormonal imbalances, such as an excess of androgens, or certain medications, not generally with undernutrition. Adequate nutrition is essential for maintaining normal hair growth cycles. Nutritional deficiencies often lead to hair thinning or loss, rather than increased growth.

Choice B rationale

A sore, inflamed buccal cavity, also known as stomatitis or mucositis, can be a direct consequence of inadequate nutrition, particularly deficiencies in B vitamins, iron, and vitamin C. These nutrients are crucial for maintaining the health and integrity of the oral mucous membranes. Inflammation and soreness can make eating painful, further contributing to poor nutrient intake.

Choice C rationale

Adequate nutrient or food intake directly contradicts the nursing diagnosis of imbalanced nutrition, less than body requirements. This finding would indicate that the patient's nutritional needs are being met, and the diagnosis would be inaccurate. The presence of dysphagia suggests difficulty in achieving adequate intake.

Choice D rationale

A weight within 10% of ideal body weight suggests that the patient's nutritional status is likely adequate, not less than body requirements. While dysphagia can lead to weight loss, a weight within the normal range indicates that the patient has been able to maintain their weight despite potential swallowing difficulties.