a nurse is planning care for a client who has dysphagia and a new dietary prescription which of the following should the nurse not include in the plan
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1. A healthcare professional is planning care for a client who has dysphagia and a new dietary prescription. Which of the following should the healthcare professional NOT include in the plan of care?

Correct answer: D

Rationale: When caring for a client with dysphagia, it is crucial to ensure safe feeding practices. Assigning an assistive personnel to feed the client slowly may not be appropriate as it can increase the risk of aspiration. Thickened liquids, having suction equipment available, and placing food on the unaffected side of the mouth are all appropriate measures to support a client with dysphagia in safe eating and drinking.

2. A client has experienced a right-hemispheric stroke. Which of the following is not an expected finding?

Correct answer: D

Rationale: In a right-hemispheric stroke, the expected findings include left-sided hemiplegia (Choice B), loss of depth perception (Choice C), and impulse control difficulty (Choice A). Aphasia (Choice D) is typically associated with left-hemispheric strokes. Therefore, aphasia is not an expected finding in a client who has experienced a right-hemispheric stroke.

3. When creating a plan of care for a newly admitted client with obsessive-compulsive disorder, which of the following interventions should the nurse take?

Correct answer: A

Rationale: Individuals with obsessive-compulsive disorder often feel compelled to perform rituals to alleviate anxiety. Allowing the client enough time to perform these rituals can help reduce their anxiety levels and promote a sense of control. Providing autonomy in scheduling activities can also empower the client and enhance their sense of independence. Discouraging exploration of irrational fears may increase anxiety and worsen symptoms. Negative reinforcement for ritualistic behaviors is not recommended as it can be counterproductive and reinforce the behavior.

4. A caregiver is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The caregiver asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the caregiver make?

Correct answer: A

Rationale: The correct response is A: 'Your baby needs an IV because she is not producing any tears.' In infants, the inability to produce tears is a sign of severe dehydration. This is a crucial indication for the need for intravenous (IV) fluid therapy to rehydrate the infant. While the other options may also be symptoms of dehydration, the absence of tears is a more direct and specific indicator requiring immediate attention and intervention.

5. When caring for a client who speaks a language different from their own, what action should the nurse take?

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

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