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

Instruct the client to tilt their head back while swallowing.

Elevate the client's head of the bed to 45° during meals.

Alternate the client's liquids and solids during meals.

Encourage the client to lie flat after meals.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Instructing a client with dysphagia to tilt their head back while swallowing can actually increase the risk of aspiration. This position opens the airway and makes it easier for food or liquid to enter the trachea instead of the esophagus, potentially leading to pneumonia or other respiratory complications.

Choice B rationale

Elevating the client's head of the bed to 45° during meals is a crucial intervention for clients with dysphagia. This semi-Fowler's position helps to utilize gravity to facilitate the passage of food and liquids down the esophagus and reduces the risk of aspiration into the airway. Maintaining this upright posture during and shortly after meals is essential for safe swallowing.

Choice C rationale

Alternating liquids and solids during meals can help manage dysphagia by reducing the bolus size and consistency that the client needs to manage at any given time. This strategy can prevent overwhelming the client's swallowing ability and decrease the risk of aspiration by allowing for better control over different food textures.

Choice D rationale

Encouraging the client to lie flat after meals is contraindicated for clients with dysphagia. Lying flat increases the risk of regurgitation and aspiration of food or liquids into the airway. Clients with swallowing difficulties should remain in an upright or semi-upright position for at least 30-60 minutes after eating to allow for proper digestion and reduce the risk of aspiration.

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Correct Answer is B

Explanation

Choice A rationale

Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.

Choice B rationale

Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.

Choice C rationale

Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.

Choice D rationale

Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.

A. "You are correct; mammography is a good replacement for BSEs.”. B. "You do not need to perform BSEs as long as a physician checks your breast annually.”. C. "While mammograms are effective, BSEs can help you become familiar with your breasts and notice changes between mammograms.”. D. "Mammograms are the only reliable way to detect breast cancer, so BSEs are unnecessary.”.

Correct Answer is C

Explanation

Choice A rationale

While mammography is a crucial tool for detecting breast cancer, particularly in women over 40, it is not a replacement for breast self-examination (BSE). Mammograms are radiographic images that can detect abnormalities, but BSE helps women become familiar with their own breasts and identify changes that may occur between mammograms.

Choice B rationale

Although annual clinical breast exams by a physician are important, they are not a substitute for monthly BSE. BSE allows women to regularly assess their breasts for any new lumps, changes in size or shape, skin thickening, or nipple discharge. These changes might occur between annual physician visits.

Choice C rationale

Mammograms are indeed effective in detecting breast cancer, often before a lump can be felt. However, BSE plays a vital role in increasing a woman's awareness of her breasts' normal texture and appearance. This familiarity enables her to notice subtle changes that may warrant further medical evaluation, complementing the benefits of mammography.

Choice D rationale

Mammograms are a highly reliable method for detecting breast cancer, especially in early stages. However, BSE is not unnecessary. It empowers women to take an active role in their breast health by promoting early detection of changes that might be indicative of cancer and can occur between scheduled mammograms.

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

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Correct Answer is C

Explanation

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