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. The nurse is caring for a client taking warfarin. Which meal brought in by the client's family is a priority to remove before the client eats it?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct answer is C. Ham is high in vitamin K, which can interfere with warfarin. Vitamin K can decrease the effectiveness of warfarin, an anticoagulant medication. Choices A, B, and D do not contain high levels of vitamin K and are less likely to interfere with the client's warfarin therapy.

3. A nurse is teaching about nutrition to a client who has a new diagnosis of chronic kidney disease. Which of the following recommendations should the nurse include in the teaching?

• A. Increase phosphorus intake
• B. Limit calcium intake
• C. Limit protein intake
• D. Increase potassium intake

Correct answer: C

Rationale: The correct recommendation for a client with chronic kidney disease is to limit protein intake. Excessive protein consumption can strain the kidneys as they work to eliminate waste products from protein metabolism. This can worsen kidney function in individuals with chronic kidney disease. Therefore, limiting protein intake is crucial in managing this condition. Choices A, B, and D are incorrect. Increasing phosphorus intake can be harmful in kidney disease as it can lead to mineral imbalances. Limiting calcium intake is not typically necessary unless the client has specific complications. Increasing potassium intake may also be inappropriate as potassium levels can be affected in kidney disease.

4. What is the fundamental difference between nursing diagnoses and collaborative problems?

• A. Collaborative problems are managed by nurses using physician-prescribed interventions.
• B. Collaborative problems can be addressed by independent nursing interventions.
• C. Physician-prescribed interventions are incorporated into nursing diagnoses.
• D. Nursing diagnoses include physiologic complications that nurses monitor to detect status changes.

Correct answer: B

Rationale: The correct answer is B, as collaborative problems necessitate the collective expertise and skills of numerous healthcare professionals, including nurses. These problems can be dealt with through independent nursing interventions in cooperation with other team members. Option A is incorrect because collaborative problems aren't strictly managed with physician-prescribed interventions. Option C is incorrect because nursing diagnoses aim at identifying and treating actual or potential health issues, rather than merely integrating physician-prescribed interventions. Option D is incorrect because nursing diagnoses aim at identifying patient issues, not solely physiologic complications, and guide the necessary nursing care, not just monitor for changes.

5. 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.

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