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

ATI RN

ATI Nutrition

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. AIDS enteropathy is most commonly manifested as _____.

A. abdominal pain and rectal bleeding
B. diarrhea and weight loss
C. abdominal bloating and flatulence
D. rectal fissures and constipation

Correct answer: B

Rationale: AIDS enteropathy typically presents as diarrhea and weight loss due to the impact of HIV on the gastrointestinal tract. While abdominal pain and rectal bleeding (Choice A), abdominal bloating and flatulence (Choice C), and rectal fissures and constipation (Choice D) can occur in some cases, the most common manifestations are diarrhea and weight loss.

3. Hypertrophic burn scars are caused by:

A. exaggerated contraction
B. random layering of collagen
C. wound ischemia
D. delayed epithelialization

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 first step in decontamination?

A. Immediately applying a chemical decontamination foam to the area of contamination
B. Thoroughly washing and rinsing the patient with soap and water
C. Immediately applying personal protective equipment
D. Removing the patient's clothing and jewelry, then rinsing the patient with water

Correct answer: D

Rationale: The correct first step in decontamination is to remove the patient's clothing and jewelry to prevent further exposure and then rinse the patient with water. This helps to eliminate any contaminants on the patient's body. Choice A is incorrect because applying a chemical decontamination foam should come after removing clothing. Choice B is incorrect as washing and rinsing the patient should follow the removal of clothing. Choice C is incorrect as personal protective equipment should be worn by the individual performing the decontamination, not applied to the patient.

5. During the first 24 hours of burn, nursing measures should focus on which of the following?

A. I and O hourly
B. Strict aseptic technique
C. Forced oral fluids
D. Isolate the patient

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.