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. As Leda’s nurse, you plan to set up an emergency equipment at her beside following thyroidectomy. You should include:

• A. An airway and rebreathing tube
• B. A tracheostomy set and oxygen
• C. A crush cart with bed board
• D. Two ampules of sodium bicarbonate

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. A nurse is caring for a client who is to receive a mechanically altered diet. Which of the following client food choices necessitates intervention by the nurse?

• A. Scrambled eggs
• B. Cottage cheese
• C. Piece of wheat toast
• D. Sliced banana

Correct answer: D

Rationale: The correct answer is 'Sliced banana.' A mechanically altered diet is designed for clients who have difficulty chewing or swallowing. Sliced bananas, due to their texture and potential choking hazard for clients with swallowing difficulties, would necessitate intervention by the nurse. Scrambled eggs, cottage cheese, and a piece of wheat toast are softer and safer options for clients on a mechanically altered diet, making them appropriate choices.

4. What is the term for a state of disequilibrium wherein a person cannot readily solve a problem or situation using their usual coping mechanisms?

• A. Crisis
• B. Mental health
• C. Mental illness
• D. Stress

Correct answer: A

Rationale: In psychological terms, a 'Crisis' refers to a state of disequilibrium wherein a person cannot readily solve a problem or situation even by using his usual coping mechanisms. This is different from 'Mental Illness' (Choice C) which is a more general term for a wide range of mental health conditions that affect mood, thinking and behavior. 'Mental Health' (Choice B) is a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. Finally, 'Stress' (Choice D) is a state of mental or emotional strain or tension resulting from adverse or demanding circumstances, but it does not necessarily disrupt equilibrium to the extent that usual coping mechanisms are ineffective, unlike 'Crisis'.

5. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

Similar Questions