an incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area the best nursing goal f an incontinent elderly client frequently wets his bed and eventually develop redness and skin excoriation at the perianal area the best nursing goal f
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Nursing Elites

ATI RN

ATI Proctored Nutrition Exam 2019

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?

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. During prenatal development, the ectoderm becomes the __________.

Correct answer: B

Rationale: The correct answer is B: nervous system and skin. The nervous system, which includes the brain, spinal cord, and nerves, as well as the skin, develop from the ectoderm layer of cells during prenatal development. Choice A is incorrect because muscles and skeleton develop from mesoderm. Choice C is incorrect because the circulatory system and other internal organs develop from mesoderm and endoderm. Choice D is incorrect because the digestive system, lungs, urinary tract, and glands develop from endoderm.

3. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. What nursing goal is appropriate for this child?

Correct answer: C

Rationale: Prednisone, an immunosuppressant, increases the child's susceptibility to infections, making infection prevention a critical nursing goal. Detecting edema and stimulating appetite are important but secondary to preventing potentially life-threatening infections.

4. Which test measures the electrical activity of the heart and can detect arrhythmias and other heart conditions?

Correct answer: A

Rationale: The correct answer is A: Electrocardiogram (ECG or EKG). An electrocardiogram is a test that measures the electrical activity of the heart and can detect arrhythmias and other heart conditions by recording the heart's electrical impulses. Choices B, C, and D are incorrect because a chest X-ray is used to visualize the structures in the chest, an MRI (Magnetic Resonance Imaging) is used to provide detailed images of organs and tissues, and a CT scan (Computed Tomography) is a type of imaging that uses X-rays to create detailed cross-sectional images of the body.

5. Your patient recently had abdominal surgery and tells you that he feels a popping sensation in his incision during a coughing spell, followed by severe pain. You anticipate an evisceration. Which supplies should you take to his room?

Correct answer: D

Rationale: For a suspected evisceration, sterile saline solution and sterile dressings should be taken to the patient's room to cover the wound and keep it moist.

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