Nursing Elites

1. A client has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

• A. Providing a straw for consumption of liquids
• B. Encouraging larger bites
• C. Placing the client in semi-Fowler's position during meals
• D. Instructing the client to tilt head forward when swallowing

Correct answer: C

Rationale: Placing the client in semi-Fowler's position during meals is the correct intervention for a client with acute dysphagia. This position helps prevent aspiration by facilitating swallowing. Providing a straw for consumption of liquids (Choice A) can increase the risk of aspiration and is not recommended for clients with dysphagia. Encouraging larger bites (Choice B) can also increase the risk of choking and aspiration. Instructing the client to tilt the head forward when swallowing (Choice D) is not the recommended technique for managing dysphagia as it does not address the underlying issue effectively.

2. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

3. When assessing older adult clients for malnutrition at an adult day care center, which risk factors should the nurse consider?

• A. Dental problems
• B. Depression
• C. Both A and B
• D. Ability to prepare meals

Correct answer: C

Rationale: The correct answer is C: Both A and B. Dental problems and depression are both significant risk factors for malnutrition in older adults. Dental problems can lead to difficulty in chewing and swallowing, resulting in reduced food intake. On the other hand, depression can cause changes in appetite and decreased interest in eating, which can also contribute to malnutrition. Although the ability to prepare meals is important, it is not specifically identified as a risk factor for malnutrition within the context of this question. Therefore, choices A and B are the most appropriate answers.

4. A nurse at a health fair is assessing the weight status of four clients. Which of the following clients is classified as overweight?

• A. A female client who has a body mass index of 24
• B. A male client who has a body mass index of 29
• C. A female client who has a waist circumference of 101.6 cm (40 in)
• D. A male client who has a waist circumference of 96.52 cm (38 in)

Correct answer: B

Rationale: A body mass index (BMI) of 25 or higher is classified as overweight. Choice B, a male client with a BMI of 29, falls into the overweight category. Choice A, a female client with a BMI of 24, is within the normal range. Choices C and D provide information on waist circumference, which is not sufficient to determine if a client is overweight or not, as waist circumference alone does not provide the overall picture of weight status compared to BMI.

5. Of the following neurotransmitters, which demonstrates inhibitory action, helps control mood and sleep, and inhibits pain pathways?

• A. Serotonin
• B. Enkephalin
• C. Norepinephrine
• D. Acetylcholine

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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