Nursing Elites

1. A nurse is assessing a client who has malnutrition. Which of the following findings should the nurse expect?

• A. Increased vital capacity
• B. Dry skin
• C. Heat intolerance
• D. Decreased mental status

Correct answer: D

Rationale: Malnutrition can lead to a variety of physical and mental symptoms. One common manifestation of malnutrition is a decreased mental status, which includes confusion, lethargy, and cognitive impairment. Dry skin is a typical finding in malnutrition due to the lack of essential nutrients needed for skin health. Heat intolerance is not a direct consequence of malnutrition. While malnutrition can affect respiratory function, it typically leads to decreased vital capacity rather than increased. Therefore, the correct answer is decreased mental status.

2. What sensation is used as a gauge so that patients with ileostomy can determine how often their pouch should be drained?

• A. Sensation of taste
• B. Sensation of pressure
• C. Sensation of smell
• D. Urge to defecate

Correct answer: B

Rationale: The correct answer is B: Sensation of pressure. Patients with ileostomy can determine how often their pouch should be drained by feeling the sensation of pressure. This is important as it helps prevent leakage or overflow of the pouch. The sensation of taste (choice A) and smell (choice C) are not typically used as gauges for draining the pouch in ileostomy patients. The urge to defecate (choice D) is not relevant in this context as patients with ileostomy do not pass stool through the rectum.

3. What information should a working mother who wants to continue breastfeeding her infant by occasionally pumping milk ahead of time be given to help her successfully maintain breastfeeding?

• A. Breast milk can be refrigerated for up to 4 days
• B. Breast milk stored in a deep freezer can be kept for up to 12 months
• C. Heating breast milk in the microwave can degrade its nutritional quality
• D. Breast milk can be expressed either by hand or with an electric pump

Correct answer: D

Rationale: The correct answer is D. This information is crucial as it informs the mother of her options for expressing milk, which is the first step in being able to store and later feed it to her child while she's away at work. Choice A has been corrected to state that breast milk can be refrigerated for up to 4 days, providing a more accurate storage timeframe. Choice B has been revised to indicate that breast milk stored in a deep freezer can be kept for up to 12 months, aligning with the recommended storage duration. Choice C now highlights that heating breast milk in the microwave can degrade its nutritional quality, emphasizing the importance of using proper methods for warming breast milk and avoiding potential harm to the baby's health and well-being.

4. Why does Anita stand in front of the mirror while performing a Breast Self-Examination (BSE)?

• A. To check for unusual discharges from the breast
• B. To check for any obvious malignancy
• C. To observe the size and contour of the breast
• D. To check for thickness and lumps in the breast

Correct answer: C

Rationale: When performing a Breast Self-Examination (BSE), one of the reasons for standing in front of a mirror is to observe the size and contour of the breast (Choice C). This helps in identifying any visible changes or abnormalities such as dimpling, puckering, or changes in the size and shape of the breasts. While unusual discharges (Choice A) and thickness or lumps (Choice D) can be part of the changes a person might notice during a BSE, these are typically identified by palpation or by squeezing the nipple for discharge, not by just looking in the mirror. Choice B, checking for obvious malignancy, is too vague and not specific enough as malignancy is often not visible to the naked eye.

5. A nurse is assessing a client who reports muscle spasms in his calves and tingling in his hands. The client indicates consuming a low intake of milk products and green leafy vegetables. The nurse should identify that the client's findings indicate a deficiency in which of the following sources of nutrition?

• A. Iron
• B. Omega-3 fatty acids
• C. Vitamin C
• D. Calcium

Correct answer: D

Rationale: The correct answer is D, Calcium. Muscle spasms and tingling suggest a calcium deficiency, which is commonly associated with a low intake of milk products and green leafy vegetables. Iron (choice A) deficiency typically presents with fatigue and weakness, not muscle spasms and tingling. Omega-3 fatty acids (choice B) are essential for brain function and heart health, but their deficiency does not manifest as muscle spasms and tingling. Vitamin C (choice C) deficiency leads to scurvy with symptoms like bleeding gums and bruising, not muscle spasms and tingling.

Similar Questions