a nurse is updating a plan of care for a client who has dysphagia what intervention should the nurse include

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ATI Capstone Fundamentals Assessment Proctored

1. A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?

A. Encourage the client to lie down after eating
B. Offer the client liquids with meals
C. Have the client sit upright for 1 hour after meals
D. Provide the client with a straw for drinking

Correct answer: C

Rationale: The correct intervention for a client with dysphagia is to have them sit upright for 1 hour after meals. This position helps facilitate swallowing and reduces the risk of aspiration, which is crucial in managing dysphagia. Encouraging the client to lie down after eating (Choice A) can increase the risk of aspiration. Offering liquids with meals (Choice B) may also increase the risk of aspiration as it can affect swallowing coordination. Providing the client with a straw for drinking (Choice D) is not recommended as straws can increase the risk of aspiration in individuals with dysphagia.

2. The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?

A. These symptoms usually result from radiation therapy; however, we will continue to monitor your laboratory and x-ray studies.
B. These symptoms are part of your disease and are an unfortunately inevitable part of living with cancer.
C. Try not to be concerned about these symptoms. Every patient feels this way after having radiation therapy.
D. Even though it is uncomfortable, this is a good sign. It means that only the cancer cells are dying.

Correct answer: A

Rationale: Fatigue and weakness are common side effects of radiation therapy, often due to the body’s response to radiation damage and the energy required to repair both cancerous and healthy cells affected by the treatment. Reassuring the patient that these symptoms are expected while also emphasizing ongoing monitoring (through lab and x-ray studies) provides both comfort and a sense of proactive care. It ensures the patient that their symptoms are being addressed in a safe and medically appropriate way.

3. A client with generalized anxiety disorder is prescribed buspirone (Buspar). Which statement by the client indicates a need for further teaching?

A. I should avoid driving while taking this medication.
B. I can stop taking this medication abruptly if I feel better.
C. It may take several weeks for this medication to take effect.
D. I should avoid using this medication during pregnancy.

Correct answer: B

Rationale: The correct answer is B. Clients should not stop taking buspirone (Buspar) abruptly as it may cause withdrawal symptoms. Choice A is correct as buspirone can cause dizziness and drowsiness, so avoiding driving is important. Choice C is also accurate because buspirone may take several weeks to reach its full effectiveness. Choice D is valid as buspirone is not recommended during pregnancy due to potential risks to the fetus.

4. The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge?

A. Surgery is recommended as soon as possible.
B. The defect usually resolves spontaneously by 3 to 5 years of age.
C. Aggressive treatment is necessary to reduce its high mortality.
D. Taping the abdomen to flatten the protrusion is not recommended.

Correct answer: B

Rationale: The correct answer is B. Most umbilical hernias in newborns resolve on their own by 3 to 5 years of age without the need for surgical intervention, unless complications arise. Surgery is not typically recommended for umbilical hernias in newborns due to the high rate of spontaneous resolution. Aggressive treatment is not necessary as umbilical hernias are typically benign and not associated with high mortality. Taping the abdomen is not recommended as it can cause skin irritation and does not speed up the resolution of the hernia.

5. A nurse is caring for a client who is receiving radiation therapy for breast cancer. Which of the following skin care instructions should the nurse provide?

A. Wear loose clothing over the radiation site.
B. Use scented lotions to moisturize the skin.
C. Apply ice packs to the radiation site for pain relief.
D. Expose the radiation site to sunlight for 20 minutes daily.

Correct answer: A

Rationale: The correct answer is A: Wear loose clothing over the radiation site. Clients receiving radiation therapy should wear loose clothing over the treatment area to prevent irritation and promote healing. Choice B is incorrect as scented lotions can irritate the skin during radiation therapy. Choice C is incorrect because ice packs should not be applied to the radiation site as they can exacerbate skin reactions. Choice D is incorrect as exposing the radiation site to sunlight can increase skin damage and should be avoided.

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ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is updating a plan of care for a client who has dysphagia. What intervention should the nurse include?

2. The clinic nurse is caring for a 42-year-old male oncology patient. He complains of extreme fatigue and weakness after his first week of radiation therapy. Which response by the nurse would best reassure this patient?

3. A client with generalized anxiety disorder is prescribed buspirone (Buspar). Which statement by the client indicates a need for further teaching?

4. The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge?

5. A nurse is caring for a client who is receiving radiation therapy for breast cancer. Which of the following skin care instructions should the nurse provide?

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