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1. A client has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Assign an assistive personnel to feed the client.
- B. Explain to the client that their tray is here and guide their hands to it.
- C. Describe to the client the location of the food on the tray.
- D. Ask the client if they would prefer a liquid diet.
Correct answer: C
Rationale: When a client has bilateral eye patches, promoting independence in eating is crucial to maintain dignity and autonomy. Describing the location of the food on the tray enables the client to locate and feed themselves. Assigning assistive personnel to feed the client (Choice A) takes away their independence. Merely informing the client that the tray is here and guiding their hands to it (Choice B) does not empower the client to eat independently. Asking if the client prefers a liquid diet (Choice D) is not directly addressing the client's ability to independently eat the current meal.
2. Legally, Patients chart are:
- A. Owned by the government since it is a legal document
- B. Owned by the doctor in charge and should be kept from the administrator for whatever reason
- C. Owned by the hospital and should not be given to anyone who request it other than the doctor in charge
- D. Owned by the patient and should be given by the nurse to the client as requested
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.
3. Protein-energy malnutrition (PEM) may be responsible for the increased incidence of noma and necrotizing ulcerative gingivitis (NUG) because these conditions are associated with depressed immune responses caused by nutritional deficiencies.
- A. Both the statement and the reason are correct and related
- B. Both the statement and the reason are correct but are not related
- C. The statement is correct, but the reason is not correct
- D. The statement is not correct, but the reason is correct
Correct answer: A
Rationale: The corrected question highlights that protein-energy malnutrition weakens the immune system, making individuals more susceptible to conditions like noma and NUG, which are linked to compromised immunity. Choice A is correct because the statement and reason are both accurate and directly related. Protein-energy malnutrition does result in depressed immune responses, which can predispose individuals to noma and NUG. Choice B is incorrect because the statement and reason are indeed related. Choice C is incorrect as both the statement and reason are accurate. Choice D is also incorrect as the statement is correct and directly supports the reason provided.
4. What is the term for intestinal wounds associated with Crohn's disease that develop in different areas in the intestine, with normal tissue separating affected regions?
- A. Skip lesions
- B. Fistulas
- C. Fissures
- D. Loop ulcerations
Correct answer: A
Rationale: Skip lesions are typical characteristics of Crohn's disease, where patches of diseased intestine are interspersed with areas of healthy tissue. This is why option A is the correct answer. Option B, fistulas, are abnormal connections between two body parts, which is not what the question is describing. Option C, fissures, are small tears in the lining of the anus, which also do not fit the description in the question. Option D, loop ulcerations, is not a recognized medical term, making it an incorrect choice.
5. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!†is an example of:
- A. Delusion of grandeur
- B. Visual Hallucination
- C. Religious delusion
- D. Auditory Hallcucination
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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