Nursing Elites

1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

2. A nurse is providing teaching to a group of adult athletes about preventing the effects of dehydration on the body. Which of the following manifestations should the nurse include in the teaching?

• A. Impaired motor control
• B. Drop in body temperature during exercise
• C. Increase in appetite
• D. Decreased resting heart rate

Correct answer: A

Rationale: Dehydration can lead to impaired motor control due to electrolyte imbalances affecting muscle function. Choices B, C, and D are incorrect. Dehydration typically causes an increase in body temperature during exercise, not a drop. Dehydration is more likely to suppress appetite, leading to a decrease rather than an increase in appetite. Also, dehydration often results in an increased heart rate rather than a decreased resting heart rate.

3. A nurse is planning care for a toddler who has burns over 50% total body surface area. Which of the following actions should the nurse include in the plan of care?

• A. Administer enteral feedings
• B. Limit intake of vitamin C
• C. Limit dietary protein
• D. Administer insulin prior to meals

Correct answer: A

Rationale: Administering enteral feedings is crucial for ensuring adequate nutrition and supporting healing in toddlers with extensive burns. Burns over 50% total body surface area can lead to increased metabolic demands, making it essential to provide nutrition through enteral feedings to meet the child's needs for healing and recovery. Limiting intake of vitamin C or dietary protein would be detrimental in this scenario as the child requires increased amounts of nutrients to support healing. Administering insulin prior to meals is not indicated in this case as the priority is to provide adequate nutrition to promote healing.

4. A client with stomatitis is receiving teaching from a nurse. Which of the following client statements indicates a need for further teaching?

• A. "I will drink liquids through a straw."?
• B. "I will season foods with dried spices before cooking."?
• C. "I will rinse my mouth with baking soda and water frequently."?
• D. "I will eat frozen bananas as a snack."?

Correct answer: C

Rationale: The correct answer is, "I will rinse my mouth with baking soda and water frequently."? Stomatitis is an inflammation of the mucous lining in the mouth, and rinsing with baking soda and water can be too abrasive and further irritate the condition. Choices A, B, and D are appropriate self-care measures for a client with stomatitis and do not indicate a need for further teaching.

5. Which mineral is a principal component of cell membranes?

• A. phosphorus
• B. magnesium
• C. iron
• D. iodine

Correct answer: A

Rationale: Phosphorus is the correct answer. It is a key component of cell membranes, being part of the phospholipid bilayer that provides structure and controls the movement of substances in and out of cells. Magnesium, iron, and iodine do not serve as principal components of cell membranes. Magnesium is involved in various enzymatic reactions, iron is essential for oxygen transport, and iodine plays a role in thyroid hormone synthesis.

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