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. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first home-care visit typically made?

• A. Within 4 days after discharge
• B. Within 24 hours after discharge
• C. Within 1 hour after discharge
• D. Within 1 week of discharge

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.

3. What is the desirable resting systolic blood pressure for adults?

• A. <130 mmHg>
• B. <105 mmHg>
• C. <120 mmHg>
• D. <140 mmHg>

Correct answer: C

Rationale: The desirable resting systolic blood pressure for adults is less than 120 mmHg. This blood pressure is associated with a lower risk of cardiovascular disease. Measurements higher than 120 mmHg (choices A and D) indicate elevated blood pressure, which can lead to hypertension and other health complications if not managed. A reading of less than 105 mmHg (choice B) could indicate low blood pressure, which also poses health risks such as dizziness and fainting.

4. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

5. What is a common symptom of vitamin D deficiency?

• A. Hair loss
• B. Night blindness
• C. Bone pain
• D. Rashes

Correct answer: C

Rationale: The correct answer is C: Bone pain. Vitamin D deficiency often leads to bone pain and weakness as it plays a crucial role in maintaining bone health by aiding in the absorption of calcium. Hair loss (choice A) is not a common symptom of vitamin D deficiency. Night blindness (choice B) is typically associated with vitamin A deficiency, not vitamin D deficiency. Rashes (choice D) are not a common symptom of vitamin D deficiency.

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