a nurse is planning care for a client who has acute dysphagia which of the following nursing interventions should be included in the plan of care
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Nursing Elites

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

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. Each of the following accurately describes features of MyPlate except one. Which one is the exception?

Correct answer: C

Rationale: The correct answer is C because MyPlate actually provides more specific guidance compared to MyPyramid. MyPlate was designed to simplify the dietary recommendations for consumers by focusing on a visual representation of a plate divided into food groups, making it easier to understand and apply. Choices A, B, and D accurately describe features of MyPlate: replacing MyPyramid, providing personalized dietary guidance through an interactive website, and grouping foods with similar nutrients while emphasizing proportionality of food selections.

3. Almost all (99%) of the calcium in the body is used for?

Correct answer: C

Rationale: The correct answer is C: providing rigidity for the bones. Almost all of the calcium in the body is utilized for maintaining the strength and structure of bones and teeth. Calcium plays a crucial role in skeletal health by providing rigidity and support to the skeletal system. Choices A, B, and D are incorrect because while calcium is essential for various physiological functions like nerve transmission, cell energy production, and muscle contraction, the majority of calcium in the body is primarily allocated for bone health.

4. The recommended treatment modality in clients with obsessive-compulsive disorder is:

Correct answer: B

Rationale: The recommended treatment modality for clients with obsessive-compulsive disorder is Behavior Therapy, not Psychoanalysis. Behavior therapy, specifically exposure and response prevention, is considered the first-line treatment for OCD. This therapy focuses on changing the patterns of behavior that contribute to the disorder. Psychotherapy, although beneficial in some cases, is not as effective as behavior therapy for OCD. Aversion therapy involves associating a stimulus with a negative outcome to reduce the frequency of a specific behavior, which is not the primary approach for OCD.

5. Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?

Correct answer: C

Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.

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