Nursing Elites

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. An elderly man is hospitalized with a diagnosis of malnutrition three months following his wife's death. What risk factor for malnutrition does this scenario illustrate?

• A. A history of chronic illness
• B. Depression or social isolation
• C. Age
• D. Impaired mobility

Correct answer: B

Rationale: This scenario illustrates depression or social isolation as a risk factor for malnutrition. After the death of his wife, the elderly man may have experienced depression or social isolation, which can lead to decreased food intake and poor nutritional status. Although age, chronic illness, and impaired mobility can also contribute to malnutrition, they are not the primary factors described in this scenario. The history of chronic illness (Choice A) and impaired mobility (Choice D) were not mentioned in the scenario, and while age (Choice C) is a factor, it's not the main factor depicted in this case.

3. The use of the Standards of Nursing Practice is important in the hospital. Which of the following statements best describes what it is?

• A. These are statements that describe the maximum or highest level of acceptable performance in nursing practice
• B. It refers to the scope of nursing practice as defined in Republic Act 9173
• C. It is a license issued by the Professional Regulation Commission to protect the public from substandard nursing
• D. The Standards of Care includes the various steps of the nursing process and the standards of professional

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. A nurse is planning to teach a client about a low-potassium diet. Which of the following foods should the nurse instruct the client to avoid?

• A. Butter
• B. Poultry
• C. Yogurt
• D. Orange juice

Correct answer: D

Rationale: Orange juice is high in potassium and should be avoided in a low-potassium diet. Butter, poultry, and yogurt are low-potassium food choices and can be included in a low-potassium diet. Poultry is a good source of lean protein, yogurt is a good source of calcium and protein, and butter is low in potassium. Therefore, the nurse should instruct the client to avoid orange juice as it is high in potassium, which is not suitable for a low-potassium diet.

5. The nurse cares for a hospitalized adolescent with the diagnosis of anorexia nervosa. Which nursing goal is a priority for this client?

• A. Encourage effective coping skills
• B. Restore normal eating habits
• C. Stop weight loss or restore weight
• D. Promote realistic self-image

Correct answer: C

Rationale: In the treatment of anorexia nervosa, stopping weight loss or restoring weight is a critical priority. This helps address the immediate health risks associated with severe malnutrition and supports the client's physical well-being. Encouraging effective coping skills, restoring normal eating habits, and promoting a realistic self-image are essential aspects of treatment but may come later in the care plan once the immediate risk of severe weight loss has been addressed.

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