Nursing Elites

1. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?

• A. Applesauce
• B. Mashed potatoes
• C. Orange slices
• D. Soft bread

Correct answer: C

Rationale: The correct answer is C: Orange slices. Orange slices contain membranes that are difficult to swallow, which can pose a risk to clients on a mechanical soft diet. This type of diet is designed for individuals who have difficulty chewing or swallowing. Choices A, B, and D are suitable for a mechanical soft diet as they are soft in texture and easy to chew and swallow.

2. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?

• A. Place weight on the underarms.
• B. Keep the elbows extended when walking.
• C. Support your weight on your hands.
• D. Hold the crutches 10 cm in front of you when standing.

Correct answer: C

Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.

3. A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following factors is strongly associated with this postpartum complication?

• A. Cesarean birth
• B. Vaginal birth
• C. Anemia
• D. Multiparity

Correct answer: A

Rationale: The correct answer is A: Cesarean birth. Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors for DVT include smoking, obesity, and a history of thromboembolism. Vaginal birth, anemia, and multiparity are not strongly associated with an increased risk of deep-vein thrombosis postpartum. It is important to educate clients undergoing cesarean birth about the increased risk of DVT and measures to prevent it, such as early ambulation and the use of compression stockings.

4. A nurse has been caring for a female client who has bruises on her arms that she explains are a result of physical abuse by her husband. The client states, “I don’t know how much longer I can take this, but I’m afraid he’ll really hurt me if I leave.” Which of the following is an appropriate nursing intervention?

• A. Offer to speak to the client’s husband regarding his abusive behavior
• B. Help the client to recognize signs of escalation in abusive behavior
• C. Assist the client in identifying personal behaviors that trigger abuse
• D. Assist the client in reporting the abusive behavior to authorities

Correct answer: D

Rationale: Assisting the client in reporting the abuse is a critical step in ensuring her safety and initiating legal action to protect her from further harm. Option A is inappropriate as it may escalate the situation and put the client at further risk. Option B focuses on the client recognizing signs of abuse, which is not as urgent as reporting it to authorities. Option C places the responsibility on the client for triggering the abuse, which is victim-blaming and not helpful in this context.

5. A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?

• A. Increase in elasticity
• B. Decrease in pigmentation
• C. Decrease in elasticity
• D. Increase in moisture levels

Correct answer: C

Rationale: The correct answer is C: 'Decrease in elasticity.' As individuals age, they typically experience a decrease in skin elasticity, leading to sagging skin and increased wrinkles. This change in elasticity can contribute to various skin-related issues such as pressure ulcers and delayed wound healing. Choices A, B, and D are incorrect because older adults do not experience an increase in elasticity or moisture levels, and while there may be changes in pigmentation, the primary change related to aging in the integumentary system is a decrease in elasticity.

Similar Questions