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. Aling Maria is nearing menopause. She is habitually taking cola and coffee for the past 20 years. You should tell Aling Maria to avoid taking caffeinated beverages because:

• A. It is stimulating
• B. It will cause nervousness and insomnia
• C. It will contribute to additional bone demineralization
• D. It will cause tachycardia and arrhythmias

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.

3. What food assistance program provides a food debit card for older adults with low incomes?

• A. the OAA Nutrition Program
• B. Meals on Wheels
• C. the Supplemental Nutrition Assistance Program
• D. the Emergency Food Assistance Program

Correct answer: C

Rationale: The correct answer is C: the Supplemental Nutrition Assistance Program (SNAP). SNAP provides a food debit card to assist low-income individuals, including older adults, in purchasing food. Choice A, the OAA Nutrition Program, is incorrect as it refers to a different program specifically focused on providing nutrition services to older adults. Choice B, Meals on Wheels, is incorrect as it is a meal delivery service for homebound individuals rather than a food debit card program. Choice D, the Emergency Food Assistance Program, is incorrect as it typically involves the distribution of emergency food supplies rather than providing a food debit card.

4. Which of the following is a tricyclic antidepressant drug?

• A. Venlafaxine (Effexor)
• B. Fluoxetine (Prozac)
• C. Sertraline (Zoloft)
• D. Imipramine (Tofranil)

Correct answer: D

Rationale: Imipramine (Tofranil) is a tricyclic antidepressant drug. This class of medications is used to treat depression, and they work by increasing the levels of certain chemicals in the brain that help lift mood. On the other hand, Venlafaxine (Effexor) is a serotonin and norepinephrine reuptake inhibitor (SNRI), Fluoxetine (Prozac) is a selective serotonin reuptake inhibitor (SSRI), and Sertraline (Zoloft) is also an SSRI. Therefore, they are not classified as tricyclic antidepressants.

5. The nurse is assessing a client with a new diagnosis of Listeria food poisoning. What action should the nurse take first?

• A. Educate the client on safe food practices.
• B. Start a traceback to identify the source of the outbreak.
• C. Report the case to the county board of health.
• D. Ask the client if they have consumed any unpasteurized products.

Correct answer: D

Rationale: The correct first action for the nurse to take when assessing a client with a new diagnosis of Listeria food poisoning is to inquire if the client has consumed any unpasteurized products. This is crucial because Listeria contamination is often associated with unpasteurized dairy products and undercooked meats. Educating the client on safe food practices (Choice A) is important but not the priority at this initial assessment stage. Starting a traceback to identify the source of the outbreak (Choice B) and reporting the case to the county board of health (Choice C) are necessary actions but should come after gathering information directly from the client regarding potential exposure to high-risk foods.

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