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A nurse is caring for a client who has dysphagia. When assisting the client during breakfast, which of the following actions by the client indicates the nurse should intervene?
- A. The client drinks their thickened juice with a straw.
- B. The client adjusts the head of their bed to 90°.
- C. The client tucks their chin when they swallow.
- D. The client takes frequent breaks while eating.
Correct Answer: A
Rationale: Correct Answer: A. The client drinking thickened juice with a straw indicates a potential aspiration risk. Straws can bypass the oral phase of swallowing, increasing the likelihood of aspiration. Thickened liquids are meant to slow down the flow of fluids to prevent choking or aspiration. Therefore, the nurse should intervene to prevent potential harm to the client.
Incorrect Choices:
B: Adjusting the head of the bed to 90° is the correct positioning to prevent aspiration during swallowing.
C: Tucking the chin when swallowing helps to protect the airway and prevent aspiration.
D: Taking frequent breaks while eating is a good strategy for clients with dysphagia to prevent fatigue and reduce the risk of aspiration.
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A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?
- A. The client turns their head against resistance.
- B. The client's tongue is in a midline position.
- C. The client's pupils constrict in response to light.
- D. The client has a symmetrical smile.
Correct Answer: D
Rationale: The correct answer is D: The client has a symmetrical smile. Cranial nerve VII, the facial nerve, controls facial expression including smiling. When assessing this nerve, the nurse would expect the client to have a symmetrical smile indicating intact function. This is because cranial nerve VII innervates the muscles of facial expression. Choices A, B, and C are incorrect as they are not specific to cranial nerve VII assessment. The turning of the head against resistance (A) would be more related to cranial nerve XI, the accessory nerve. The tongue position (B) is controlled by cranial nerve XII, the hypoglossal nerve. Pupillary constriction in response to light (C) is regulated by cranial nerve II, the optic nerve.
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply.)
- A. The client speaks the same language as the nurse.
- B. The client has legal authority to do so.
- C. The client does not have a mental health condition.
- D. The client signed in the nurse's presence.
- E. The client was not coerced.
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. B is essential as the client must have legal authority to give informed consent. D is crucial as the client's signature in the nurse's presence ensures authenticity. E is important to confirm that the client was not coerced. Choice A is incorrect as language proficiency does not determine consent validity. Choice C is incorrect as having a mental health condition does not automatically invalidate consent.
A home health nurse is providing teaching about home safety to an older adult client. Which of the following examples of home safety should the nurse include in the teaching?
- A. Obtain a raised toilet seat for the bathroom.
- B. Secure loose wires under carpeting.
- C. Use extension cords to prevent overloading circuits.
- D. Cover slippery stairs with an area rug.
Correct Answer: A
Rationale: The correct answer is A: Obtain a raised toilet seat for the bathroom. This is important for older adults to prevent falls and make it easier for them to use the toilet safely. Raised toilet seats reduce the risk of strain or injury while sitting down or getting up.
Incorrect choices:
B: Securing loose wires under carpeting can still pose a tripping hazard.
C: Using extension cords can lead to electrical hazards and fires.
D: Covering slippery stairs with an area rug can increase the risk of falls due to slipping.
A nurse is teaching a class about the guidelines for the standards of care for nursing. Which of the following defines the nursing scope of practice?
- A. The JEN Consultant
- B. Podcast League for Nursing
- C. Postnote ID # of Rights
- D. State Nurse Practice Acts
Correct Answer: D
Rationale: The correct answer is D: State Nurse Practice Acts. State Nurse Practice Acts define the legal scope of practice for nurses in each state, outlining what tasks and responsibilities nurses can perform. These acts help ensure patient safety and quality care by setting standards for nursing practice. Choice A, B, and C are unrelated to nursing scope of practice and do not provide any guidelines or regulations for nurses. Therefore, they are incorrect options.
A nurse is caring for a client who has a traumatic brain injury and needs to relearn how to use eating utensils. The nurse should refer the client to which of the following members of the interprofessional team?
- A. Physical therapist
- B. Speech-language pathologist
- C. Occupational therapist
- D. Social worker
Correct Answer: C
Rationale: The correct answer is C: Occupational therapist. Occupational therapists specialize in helping individuals regain skills needed for daily activities, such as using eating utensils. They focus on enhancing fine motor skills and cognitive abilities necessary for independent living. Referring the client to an occupational therapist will ensure a comprehensive approach to relearning utensil use. Physical therapists (A) focus on mobility and strength, not fine motor skills. Speech-language pathologists (B) address communication and swallowing issues, not utensil use. Social workers (D) assist with psychosocial support, not utensil retraining.