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. Aling Maria is nearing menopause. She is habitually taking cola and coffee for the past 20 years. You should tell Aling Maria to avoid taking caffeinated beverages because:

• A. It is stimulating
• B. It will cause nervousness and insomnia
• C. It will contribute to additional bone demineralization
• D. It will cause tachycardia and arrhythmias

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

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.

4. A nurse is caring for a client who has a body mass index (BMI) of 30. Four weeks after nutritional counseling, which of the following evaluation findings indicates the plan of care was followed?

• A. BMI of 25
• B. Weight gain of 1.8 kg
• C. BMI of 33
• D. Weight loss of 2.7 kg

Correct answer: D

Rationale: A weight loss of 2.7 kg in four weeks indicates effective adherence to a nutritional plan aimed at reducing body mass index (BMI), moving towards a healthier weight. Choices A, B, and C are incorrect because a decrease in weight, as shown in choice D, is the desired outcome when managing a client with a BMI of 30 to reach a healthier range.

5. Which food is most likely to be included in a low-fiber diet?

• A. Broccoli
• B. Ripe Bananas
• C. Onions
• D. Whole-Grain Bread

Correct answer: B

Rationale: A low-fiber diet is generally recommended for individuals who need to restrict their intake of dietary fiber for health reasons. Ripe bananas are low in fiber and easy to digest, making them an ideal choice for a low-fiber diet. On the other hand, broccoli, onions, and whole-grain bread are high in fiber. Therefore, they are less suitable for a low-fiber diet as they could cause digestive discomfort or exacerbate certain health conditions. Ripe bananas, being low in fiber, are the most appropriate choice for a low-fiber diet.

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