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. Which of the following foods should be avoided by patients experiencing xerostomia, except one? Which is the exception?

• A. Saltines
• B. Salsa
• C. Alcohol
• D. Dill pickles

Correct answer: D

Rationale: The correct answer is Dill pickles. Unlike the other choices, which can exacerbate xerostomia due to their dry or irritating nature, dill pickles, being tart and sour, can actually help stimulate saliva flow, which is beneficial for patients with xerostomia. Saltines, salsa, and alcohol are all known to contribute to dry mouth and should generally be avoided by individuals experiencing xerostomia.

3. A nurse is providing teaching to a group of parents of newborns who are planning to formula feed. Which of the following statements by a parent indicates a need for further teaching?

• A. "I will give formula to my baby at room temperature."
• B. "I will ensure my baby's feeds last 10 to 15 minutes."
• C. "I will burp my baby halfway through each feeding."
• D. "I will watch for signs my baby is full and stop the feeding."

Correct answer: B

Rationale: The correct answer is, "I will ensure my baby's feeds last 10 to 15 minutes." This statement indicates a need for further teaching because it suggests a strict time limit for feedings, which may not be appropriate for a newborn. Newborns should be allowed to feed as long as they want, typically around 20-30 minutes per breast if breastfeeding, or on-demand with formula. Choices A, C, and D demonstrate proper feeding practices such as feeding at room temperature, burping halfway through each feeding, and watching for signs of fullness to stop the feeding, which are all appropriate responses by a parent of a formula-fed newborn.

4. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

• A. Self-esteem disturbance
• B. Impaired urinary elimination
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

5. Is the loss of teeth or supporting periodontium often associated with poor food selection and limited chewing ability, and do the patients' masticatory efficiency and biting force decline with each tooth lost?

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: A

Rationale: Both statements are indeed true. The loss of teeth or supporting periodontium frequently leads to poor food selection and limited chewing ability, as these conditions can make certain foods difficult to consume. Additionally, a patient's masticatory efficiency and biting force do decline with each tooth lost, as there are fewer teeth to distribute the force of the bite. Choices B, C, and D are incorrect because they suggest that one or both of these statements are false, which is not the case.

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