Nursing Elites

1. The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:

• A. Narrowing of the pulse pressure
• B. Vomiting
• C. Periorbital edema
• D. A positive Kernig's sign

Correct answer: C

Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.

2. The term associated with loss of taste is:

• A. Xerostomia
• B. Hypogeusia
• C. Dysphagia
• D. Anosmia

Correct answer: B

Rationale: The correct answer is B, 'Hypogeusia.' Hypogeusia refers to a diminished sense of taste, which can impact nutritional intake, especially in older adults. Xerostomia (choice A) is dry mouth, Dysphagia (choice C) is difficulty swallowing, and Anosmia (choice D) is the loss of the sense of smell. These conditions are different from loss of taste, making them incorrect choices for this question.

3. 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.

4. What best describes a task of the registered dietitian?

• A. administering total parenteral nutrition
• B. administering formula through feeding tubes
• C. prescribing diet orders
• D. conducting nutrition assessments

Correct answer: D

Rationale: The correct answer is D, conducting nutrition assessments. Registered dietitians are responsible for assessing an individual's nutritional status, dietary intake, and health needs. This assessment forms the basis for developing personalized nutrition care plans. Choices A and B involve the administration of specialized nutrition support, which is typically done by healthcare providers with specific training in those areas. Choice C, prescribing diet orders, may fall outside the scope of practice for a dietitian as they focus more on assessment, education, and counseling related to nutrition rather than prescribing medical treatments.

5. A nurse is providing dietary teaching for a client who has just learned that she has type 2 diabetes mellitus. The nurse should explain that which of the following sweeteners will add calories to the client's carbohydrate count?

• A. Sorbitol
• B. Sucralose
• C. Aspartame
• D. Acesulfame potassium

Correct answer: A

Rationale: Sorbitol is a sweetener that will add calories to the client's carbohydrate count. It is a sugar alcohol that provides about 2.6 calories per gram. Sucralose, aspartame, and acesulfame potassium are all non-nutritive sweeteners that do not contribute significant calories to the diet. Sucralose is about 600 times sweeter than sucrose but does not add calories. Aspartame is a low-calorie sweetener that is approximately 200 times sweeter than sucrose, and acesulfame potassium is a calorie-free sweetener.

Similar Questions