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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. In which of the following conditions does a person need to sit, stand, or use multiple pillows when lying down?
- A. Orthopnea
- B. Dyspnea
- C. Eupnea
- D. Apnea
Correct answer: A
Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.
3. You are on duty in the medical ward. The mother of your patient who is also a nurse, came running to the nurses station and informed you that Fiolo went into cardiopulmonary arrest.
- A. Start basic life support measures
- B. Call for the Code
- C. Bring the crash cart to the room
- D. Go to see Fiolo and assess for airway patency and breathing problems
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. What is the term for a state of disequilibrium wherein a person cannot readily solve a problem or situation using their usual coping mechanisms?
- A. Crisis
- B. Mental health
- C. Mental illness
- D. Stress
Correct answer: A
Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.
5. Earliest sign of skin reaction to radiation therapy is:
- A. desquamation
- B. erythema
- C. atrophy
- D. pigmentation
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.
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