You are caring for a patient with achalasia. Which interventions should you prioritize in the plan of care? (Select all that apply)
Have oropharyngeal suctioning equipment at the bedside
Arrange for small, frequent meals
Allow patient to consume thickened fluids only
Administer antiemetics before meals
Position patient with head of bed elevated
Correct Answer : A,B,D,E
Choice A reason: Achalasia increases aspiration risk due to esophageal dysmotility. Oropharyngeal suctioning equipment at the bedside ensures airway safety, making this a critical intervention to prioritize in the care plan.
Choice B reason: Small, frequent meals reduce esophageal pressure in achalasia, easing swallowing and minimizing regurgitation. This dietary adjustment is essential for symptom management, making it a correct intervention to prioritize.
Choice C reason: Thickened fluids only may not be necessary; achalasia patients can often manage various consistencies with proper positioning. Other interventions like suctioning and small meals are more critical, so this is incorrect.
Choice D reason: Antiemetics before meals reduce nausea and vomiting, common in achalasia due to food retention. This improves patient comfort and nutrition, making it a correct intervention to prioritize in care.
Choice E reason: Elevating the head of the bed prevents regurgitation and aspiration in achalasia, especially during sleep. This positioning is a key safety measure, making it a correct intervention to prioritize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Infarction is permanent tissue death from prolonged blood loss, not temporary deprivation. Ischemia describes reversible reduced blood supply, matching the question, so this is incorrect.
Choice B reason: Ischemia is the temporary deprivation of blood supply to cells, causing reduced oxygen delivery but potentially reversible damage. This fits the description, making it the correct term.
Choice C reason: Necrosis is irreversible cell death, not temporary blood supply loss. Ischemia is the term for reversible deprivation, so this is incorrect for the described condition.
Choice D reason: Inflammation is a response to injury, not blood supply deprivation. Ischemia specifically refers to temporary reduced blood flow, so this is incorrect for the term.
Correct Answer is D
Explanation
Choice A reason: Retching is the involuntary attempt to vomit, involving abdominal muscle contractions without expelling stomach contents. The patient is actively expelling contents, which defines vomiting, not just the effort of retching, making this an incorrect term for documentation.
Choice B reason: Expectorate refers to coughing up and spitting out mucus or sputum from the respiratory tract. The patient is expelling stomach contents, not respiratory secretions, making expectorate an incorrect term for this gastrointestinal event.
Choice C reason: Regurgitation is the passive return of undigested food or liquid from the stomach or esophagus, often without force. The forceful expulsion of stomach contents described indicates vomiting, not regurgitation, making this an incorrect documentation term.
Choice D reason: Vomiting is the forceful expulsion of stomach contents through the mouth, driven by coordinated abdominal and diaphragmatic contractions. The patient’s active expulsion into a basin matches this definition, making vomiting the correct term for documentation.
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