Nursing Elites

1. A client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

• A. Assign an assistive personnel to feed the client.
• B. Explain to the client that their tray is here and guide their hands to it.
• C. Describe to the client the location of the food on the tray.
• D. Ask the client if they would prefer a liquid diet.

Correct answer: C

Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.

2. A client who has dumping syndrome following a hemi-colectomy should avoid which of the following foods when receiving nutritional teaching from a nurse?

• A. Rice
• B. Poached eggs
• C. Fresh apples
• D. White bread

Correct answer: C

Rationale: Fresh apples should be avoided by a client with dumping syndrome following a hemi-colectomy because they are high in fiber and can exacerbate gastrointestinal symptoms such as diarrhea and bloating. Rice and poached eggs are good options as they are easily digestible and less likely to trigger dumping syndrome symptoms. White bread is also preferable over whole grain bread due to its lower fiber content, making it a better choice for individuals with dumping syndrome.

3. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

4. Patients with congestive heart failure need to restrict their intake of:

• A. fiber
• B. sodium
• C. cholesterol
• D. saturated fat

Correct answer: B

Rationale: Patients with congestive heart failure need to restrict their intake of sodium. This restriction is crucial to prevent fluid retention, which can exacerbate the condition. While fiber is generally beneficial for heart health, sodium restriction is more critical in this scenario. Cholesterol and saturated fat intake should also be monitored, but sodium restriction takes precedence due to its direct impact on fluid balance.

5. What is the function of villi and microvilli in the GI tract?

• A. produce bile
• B. kill bacteria
• C. produce vitamin K
• D. increase the surface area for absorption

Correct answer: D

Rationale: Villi and microvilli in the GI tract serve to increase the surface area of the small intestine, aiding in the absorption of nutrients into the bloodstream. Choices A, B, and C are incorrect as villi and microvilli are primarily involved in enhancing absorption, not in producing bile, killing bacteria, or producing vitamin K.

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