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. Nutritional goals for a patient wishing to modify eating patterns should adhere to each, except one. Which is the exception?

• A. Measurable
• B. Immediate
• C. Realistic
• D. Achievable

Correct answer: B

Rationale: Nutritional goals should be measurable, realistic, and achievable. They should not be immediate, as sustainable changes take time.

3. 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.

4. Which is the priority nursing diagnosis for a patient with an indwelling urinary catheter?

• A. Self-esteem disturbance
• B. Impaired urinary elimination
• C. Impaired skin integrity
• D. Risk for infection

Correct answer: D

Rationale: The correct answer is 'D: Risk for infection.' An indwelling urinary catheter poses a significant risk for infection due to its invasive nature and the increased susceptibility to urinary tract infections. While 'B: Impaired urinary elimination' and 'C: Impaired skin integrity' may also be concerns for a patient with an indwelling urinary catheter, the immediate risk of infection is the priority. 'A: Self-esteem disturbance' is not typically a priority nursing diagnosis for a patient with an indwelling urinary catheter because the focus is primarily on infection prevention and management to ensure patient safety and well-being.

5. In consideration of the steps in applying the bag technique, which side of the paper lining of the CHN bag is considered clean to make a non-contaminated work area?

• A. The lower lip
• B. The outer surface
• C. The upper tip
• D. The inside surface

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.

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