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 understands that one of these factors contributes to constipation:

• A. excessive exercise
• B. high fiber diet
• C. no regular time for defecation daily
• D. prolonged use of laxatives

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. To prevent recurrent attacks on client with glomerulonephritis, the nurse instructs the client to:

• A. Take a shower instead of tub baths
• B. Avoid situations that involve physical activity
• C. Continue the same restriction on fluid intake
• D. Seek early treatment for respiratory infection

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.

4. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

• A. Interview the client for chief complaints and other symptoms
• B. Talk to the relatives to gather data about history of illness
• C. Do auscultation to check for chest congestion
• D. Do a physical examination while asking the client relevant questions

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. A 52-year-old male patient recently required surgery for the removal of a large calcium oxalate stone. To prevent further stone formation, the nurse advises against drinking?

• A. apple juice
• B. tea
• C. orange juice
• D. coffee

Correct answer: B

Rationale: Tea contains oxalates, which can contribute to the formation of calcium oxalate stones; therefore, patients prone to kidney stones should avoid excessive tea consumption.

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