Nursing Elites

1. For an incontinent elderly client who frequently wets his bed and develops redness and skin excoriation at the perianal area, what is the best nursing goal?

• A. Ensure that the bed linen is always dry
• B. Frequently check the bed for wetness and keep it dry
• C. Place a rubber sheet under the client's buttocks
• D. Keep the patient clean and dry

Correct answer: A

Rationale: The best nursing goal for an incontinent elderly client with skin excoriation is to ensure that the bed linen is always dry. This helps in preventing further skin breakdown and promoting skin integrity. Choice B, to frequently check the bed for wetness and keep it dry, may not address the issue of prevention if the linen is not consistently dry. Choice C, placing a rubber sheet under the client's buttocks, focuses more on protecting the mattress rather than addressing the client's skin condition directly. Choice D, keeping the patient clean and dry, is important but does not specifically address the preventive aspect of maintaining dry bed linen.

2. A nurse is teaching a client about iron-rich foods. Which food is the best source of heme iron?

• A. Spinach
• B. Lentils
• C. Beef liver
• D. Tofu

Correct answer: C

Rationale: Heme iron, found in animal products like beef liver, is more easily absorbed than non-heme iron from plant sources.

3. A nurse is caring for a client who is lactose intolerant. Which of the following clinical manifestations should the nurse assess?

• A. Fever
• B. Blood in stools
• C. Cramping
• D. Steatorrhea

Correct answer: C

Rationale: The correct answer is C: Cramping. Cramping is a common clinical manifestation of lactose intolerance due to the inability to digest lactose properly. Fever (choice A) is not typically associated with lactose intolerance. Blood in stools (choice B) is more indicative of other gastrointestinal issues like inflammatory bowel disease. Steatorrhea (choice D) is the presence of excess fat in the stool and is not a typical symptom of lactose intolerance.

4. A client is being educated by a nurse on snacks suitable for a low-fat, low-sodium, and low-cholesterol diet. Which of the following food choices by the client indicates the need for further teaching?

• A. A slice of cheese
• B. A jam sandwich
• C. A cup of plain popcorn
• D. A small container of applesauce

Correct answer: A

Rationale: The correct answer is A: A slice of cheese. Cheese is high in fat, sodium, and cholesterol, making it unsuitable for a low-fat, low-sodium, and low-cholesterol diet. Choices B, C, and D are more appropriate for such a diet. B: A jam sandwich can be low in fat, sodium, and cholesterol if made with whole grain bread and a low-sugar jam. C: A cup of plain popcorn is a good choice as it is low in fat and can be made without added salt. D: A small container of applesauce is also a suitable option for a low-fat, low-sodium, and low-cholesterol diet.

5. How many words does a typical 12-month-old infant use?

• A. About 12 words
• B. Twenty or more words
• C. About 50 words
• D. Two, plus 'mama' and 'papa'

Correct answer: D

Rationale: A typical 12-month-old infant typically uses very few words, with 'mama' and 'papa' being common early words. At this age, most infants are still in the early stages of language development, and their vocabulary is limited. Choices A, B, and C suggest higher word counts which are not typical for infants at this age.

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