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. After ileostomy, which of the following condition is NOT expected?

• A. Increased weight
• B. Irritation of skin around the stoma
• C. Liquid stool
• D. Establishment of regular bowel movement

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

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. After bronchoscopy, the nurse's priority is to check which of the following before feeding?

• A. Gag reflex
• B. Wearing off of anesthesia
• C. Swallowing reflex
• D. Peristalsis

Correct answer: A

Rationale: After a bronchoscopy procedure, the nurse's priority is to check the patient's gag reflex before allowing them to eat to prevent aspiration. The gag reflex helps protect the airway by triggering a cough or gag response if something touches the back of the throat. This is crucial to ensure that the patient can protect their airway and prevent food or fluids from entering the lungs, especially when the throat may be sensitive or compromised post-bronchoscopy. Checking for the wearing off of anesthesia, swallowing reflex, or peristalsis are important assessments but not the immediate priority before feeding in this context.

5. Children with cerebral palsy, Down syndrome, and intellectual disabilities are likely to have abnormal sensory input and muscle tone. A small, underdeveloped tongue is common in many such disorders and results in diminished nutritional status.

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: C

Rationale: The first statement is true, but the second is false. These children often have a large tongue or tongue thrust, which can interfere with feeding and nutrition.

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