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. In a patient with liver cirrhosis, weight gain due to fluid retention can mask the symptoms of what condition?

• A. Liver failure
• B. Gallbladder disease
• C. Heart failure
• D. Protein-Energy Malnutrition (PEM)

Correct answer: D

Rationale: In a patient with liver cirrhosis, weight gain due to fluid retention can mask Protein-Energy Malnutrition (PEM) symptoms. This can lead to an increase in weight, making it challenging to identify weight loss or muscle wasting associated with PEM. Therefore, option D is correct. Options A, B, and C are incorrect because fluid retention and weight gain related to liver cirrhosis do not necessarily hide the symptoms of liver failure, gallbladder disease, or heart failure.

3. Earliest sign of skin reaction to radiation therapy is:

• A. desquamation
• B. erythema
• C. atrophy
• D. pigmentation

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

4. What symptom would most likely be associated with late dumping syndrome?

• A. abdominal cramps
• B. nausea
• C. diarrhea
• D. confusion

Correct answer: D

Rationale: Confusion is the most likely symptom associated with late dumping syndrome. Late dumping syndrome occurs when blood sugar levels drop rapidly after eating due to rapid gastric emptying. While abdominal cramps, nausea, and diarrhea can occur with dumping syndrome, confusion is specifically linked to late dumping syndrome due to hypoglycemia.

5. AIDS enteropathy is most commonly manifested as _____.

• A. abdominal pain and rectal bleeding
• B. diarrhea and weight loss
• C. abdominal bloating and flatulence
• D. rectal fissures and constipation

Correct answer: B

Rationale: AIDS enteropathy typically presents as diarrhea and weight loss due to the impact of HIV on the gastrointestinal tract. While abdominal pain and rectal bleeding (Choice A), abdominal bloating and flatulence (Choice C), and rectal fissures and constipation (Choice D) can occur in some cases, the most common manifestations are diarrhea and weight loss.

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