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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 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.
3. What is the rationale in the use of bag technique during home visits?
- A. It helps render effective nursing care to clients or other members of the family
- B. It saves time and effort of the nurse in the performance of nursing procedures
- C. It should minimize or prevent the spread of infection from individuals to families
- D. It should not overshadow concerns for the patient
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. Which of the following statements are true about iron?
- A. The iron needs of vegans are 20% higher, and the needs of endurance athletes are 10% lower.
- B. It is one of the most common nutrient deficiencies in the world.
- C. Its absorption is increased by Vitamin C and during pregnancy.
- D. Its absorption is increased by tannic acid and calcium in milk.
Correct answer: C
Rationale: Choice C is correct because iron absorption is indeed increased by Vitamin C and during pregnancy. The other choices are incorrect. Choice A is wrong as there are no universally accepted percentages for the iron needs of vegans and endurance athletes. Choice B is inaccurate as iron deficiency is actually one of the most common nutritional deficiencies worldwide. Choice D is incorrect because tannic acid and calcium in milk actually inhibit iron absorption rather than increasing it.
5. Which is NOT a characteristic or function of lipids?
- A. Involved in energy metabolism and storage
- B. Provide insulation and protection
- C. Act as hormones that regulate the body
- D. Are hydrophilic
Correct answer: D
Rationale: Lipids are known for several functions including involvement in energy metabolism and storage (Choice A), providing insulation and protection (Choice B), and acting as hormones that regulate the body (Choice C). However, lipids are not hydrophilic (water-attracting), contrary to choice D. They are actually hydrophobic, meaning they repel water and do not mix well with it. This is a key property that differentiates them from many other biological molecules.
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