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. What special consideration should be taken into account when Mario prepares Richard for postural drainage and percussion?

• A. Monitoring a respiratory rate of 16 to 20 per minute
• B. Assessing the client's ability to tolerate sitting and lying positions
• C. Ensuring the client is free of signs of infection
• D. Knowing the time of the client's last food and fluid intake

Correct answer: A

Rationale: The correct answer is A, 'Monitoring a respiratory rate of 16 to 20 per minute'. When performing postural drainage and percussion, it is crucial to monitor the respiratory rate to ensure the safety and effectiveness of the procedure. Choice B, 'Assessing the client's ability to tolerate sitting and lying positions', while important, is not directly related to the specifics of postural drainage and percussion. Similarly, option C, 'Ensuring the client is free of signs of infection', although important, is not directly linked to the procedure. Option D, 'Knowing the time of the client's last food and fluid intake', might be relevant for other procedures, but it is not the primary consideration for postural drainage and percussion.

3. A client is on a 2,000-calorie American Diabetes Association (ADA) diet and substitutes whole milk with skim milk. Which of the following items can the client add to the oatmeal on his breakfast tray?

• A. One 1/8 teaspoon of salt
• B. One ounce of raisins
• C. One tablespoon of low-fat margarine
• D. One teaspoon of brown sugar

Correct answer: B

Rationale: The correct answer is one ounce of raisins. Raisins are a healthy option to add to oatmeal as they provide natural sweetness without added sugars. They are a good source of fiber and essential nutrients. Option A, one 1/8 teaspoon of salt, is not necessary for flavoring oatmeal. Option C, one tablespoon of low-fat margarine, may add unnecessary fat to the meal. Option D, one teaspoon of brown sugar, adds extra sugar, which should be limited in a diabetes-friendly diet.

4. Which of the following suggestions is the healthiest for Miguel, who is always hungry and never seems to feel full despite eating enough calories?

• A. Switch out energy-dense foods with more nutrient-dense foods that are more likely to make him feel full
• B. Drink adequate amounts of water
• C. A, B
• D. Eat foods with more fat, as fat slows gastric emptying and will make him feel more full

Correct answer: C

Rationale: The correct answer is A and B. Switching to more nutrient-dense foods can help Miguel feel full despite eating enough calories. Nutrient-dense foods provide essential nutrients and are more satisfying. Drinking adequate water is also crucial for overall health and can help with feelings of fullness. Choice D is incorrect because while fat can contribute to satiety, it should be consumed in balance with other nutrients. Consuming foods with high fat content excessively may lead to other health issues and does not address the underlying problem of feeling constantly hungry despite eating.

5. What describes a common physical change of aging that can affect an older adult's nutrition?

• A. reduced salivary output
• B. increased gastrointestinal motility
• C. abnormal cortisol production
• D. increase in number of taste buds

Correct answer: A

Rationale: Reduced salivary output is a common physical change in aging. This can affect an older adult's nutrition by impacting chewing, swallowing, and taste perception. The decrease in saliva production can make it harder to chew and swallow food effectively, affecting the overall eating experience. Additionally, saliva plays a role in taste perception, so a reduction in salivary output can lead to alterations in how food tastes, potentially impacting an individual's appetite and food choices. Increased gastrointestinal motility (choice B) is not typically associated with aging and would not directly affect nutrition. Abnormal cortisol production (choice C) is related to hormonal changes and is not a common physical change of aging that affects nutrition. An increase in the number of taste buds (choice D) is not a typical change associated with aging and would not have a significant impact on an older adult's nutrition.

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