Paramedics have brought a patient to the emergency department with a suspected heroin overdose. The nurse should recognize that the patient's most acute threat to health at this time is:

A. Ensure that there is a complete and functional suction system at the bedside. This is an essential precaution for clients with dysphagia because they are at high risk of aspiration. Having suction equipment ready allows for quick intervention if the client begins to choke or aspirate.

B. Position the head of the client's bed at a height of 30° to 45°. This positioning is too low for feeding. To reduce the risk of aspiration, the head of the bed should be elevated to at least 45° to 90° during feeding. Therefore, this option is less safe.

C. Provide two larger meals each day rather than three smaller meals in order to prevent fatigue. Smaller, more frequent meals are generally recommended to prevent fatigue and reduce the risk of aspiration, as larger meals can be overwhelming and increase the risk of choking.

D. Encourage the client to hold her breath while she is attempting to swallow. This is not a standard or safe practice for managing dysphagia. Safe swallowing techniques typically include ensuring the client is alert, properly positioned, and eating slowly with small bites.

A. "I wouldn't tell if I were you." This response is inappropriate because it imposes the nurse's personal opinion rather than supporting the family in making an informed decision.

B. "In my experience, clients who know are more likely to be involved with their plan of care." This is the best response because it encourages transparency and patient autonomy, allowing the client to participate in their care decisions.

C. "The shock of learning the diagnosis may be too much stress for an elderly person.” This response is not based on evidence and may discourage the family from being honest with the client, which could prevent the client from making informed decisions.

D. "This is a private concern that should include the physician, not me." While the physician should be involved in the discussion, the nurse also plays a crucial role in providing support and guidance to the family. This response dismisses the nurse's role in the situation.