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 A
Explanation
Choice A reason: Lethargy is a common manifestation of hypothyroidism, resulting from slowed metabolism due to low thyroid hormone levels. It leads to fatigue and reduced energy, aligning with hypothyroid symptoms, making it a correct choice for clinical manifestations.
Choice B reason: Constipation is a hallmark of hypothyroidism, caused by decreased gastrointestinal motility from low thyroid hormone. This digestive slowing is a frequent complaint, making it a correct selection for hypothyroidism’s clinical manifestations.
Choice C reason: Restlessness is associated with hyperthyroidism, not hypothyroidism, which causes lethargy and slowed activity. Hypothyroid patients lack the agitation seen in hyperthyroid states, so this is incorrect for hypothyroidism manifestations.
Choice D reason: Intolerance to heat is a hyperthyroidism symptom, not hypothyroidism, where patients experience cold intolerance due to slowed metabolism. This is opposite to hypothyroid effects, so it’s incorrect for hypothyroidism’s clinical manifestations.
Correct Answer is C
Explanation
Choice A reason: Linking high potassium to kidney function risk is inaccurate; hyperkalemia primarily affects cardiac and neuromuscular function. Numbness, tingling, or weakness are direct symptoms, making this statement less relevant for patient education and incorrect.
Choice B reason: Changing IV fluids may be a treatment but doesn’t explain the issue or engage the patient. Asking to report numbness, tingling, or weakness directly addresses hyperkalemia symptoms, making this less appropriate and incorrect.
Choice C reason: High potassium (6.1 mEq/L) can cause numbness, tingling, or weakness. Instructing the patient to report these symptoms ensures early detection of worsening hyperkalemia, making this the correct, patient-centered statement for education.
Choice D reason: Palpitations may occur, but numbness, tingling, and weakness are more specific to hyperkalemia’s neuromuscular effects. “Quick beating” is less precise for heart rhythm issues, so this is incorrect compared to option c.
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