Nursing Elites

1. When assessing for criteria that signify malnutrition risk, which element would most likely be included as part of the functional assessment data?

• A. severity of illness
• B. presence of pressure sores
• C. localized edema
• D. generalized weakness

Correct answer: D

Rationale: Generalized weakness is a key indicator of malnutrition and is often assessed as part of functional status, reflecting muscle wasting and reduced physical function. The other choices, such as severity of illness, presence of pressure sores, and localized edema, are important factors to consider in a clinical assessment but are not primarily indicative of malnutrition risk. Generalized weakness directly relates to the functional impact of malnutrition on physical performance.

2. Why are blood glucose levels high in type 1 diabetes?

• A. The urinary excretion of glucose is impaired
• B. The lean body mass is metabolized to produce glucose via gluconeogenesis
• C. The absorption of glucose from the gastrointestinal tract is more efficient
• D. There is insufficient insulin to facilitate the transport of glucose into the cells

Correct answer: D

Rationale: In type 1 diabetes, the body's immune system destroys the beta cells in the pancreas that produce insulin. This leads to an insufficient amount of insulin, which is required to facilitate the transport of glucose into the cells. Consequently, blood glucose levels remain high. The other options are incorrect. Option A is incorrect because urinary excretion of glucose does not directly contribute to blood glucose levels. Option B is incorrect because, while gluconeogenesis does produce glucose, it is not the cause of high glucose levels in type 1 diabetes. Option C is incorrect because absorption efficiency of glucose from the gastrointestinal tract does not affect the amount of insulin available to transport glucose into cells.

3. A nurse is instructing the mother of a toddler who has iron-deficiency anemia to increase iron in the child's diet in addition to the prescribed iron supplement. Which of the following foods should the nurse recommend?

• A. Skim milk
• B. Bananas
• C. Tuna fish
• D. Cucumbers

Correct answer: C

Rationale: Tuna fish is a good source of iron and would be beneficial for a toddler with iron-deficiency anemia. Skim milk, bananas, and cucumbers are not significant sources of iron and would not help in increasing the iron levels in the child's diet. Skim milk, in particular, can inhibit iron absorption due to its calcium content, which is important for the nurse to educate the mother about.

4. A client reports having difficulty losing weight. Which of the following responses by the nurse is appropriate?

• A. Eat small portions of high-calorie foods first.
• B. Set a goal, and you will be able to attain it.
• C. It is helpful to self-monitor your eating.
• D. Taste food while cooking to help curb your appetite.

Correct answer: C

Rationale: The correct answer is C: 'It is helpful to self-monitor your eating.' Self-monitoring dietary intake is an evidence-based strategy that enhances awareness and accountability, making it an effective approach for weight management. Choice A is incorrect as focusing on high-calorie foods first may not be the most effective strategy for weight loss. Choice B is too general and lacks actionable advice. Choice D, tasting food while cooking, does not directly address the client's difficulty in losing weight and is not a proven method for weight management.

5. Which of the following interventions should be considered the highest priority when caring for June, who has hemiparesis secondary to a stroke?

• A. Position June in an upright lateral position
• B. Perform range of motion exercises
• C. Apply antiembolic stockings
• D. Use hand rolls or pillows for support

Correct answer: C

Rationale: The correct answer is C, 'Apply antiembolic stockings'. In the case of a patient who has experienced a stroke and is suffering from hemiparesis, the highest priority intervention is to prevent further complications such as deep vein thrombosis (DVT), which can be life-threatening. Antiembolic stockings are used to increase venous blood flow velocity and reduce the risk of DVT. Choice 'A', positioning June in an upright lateral position, while important for overall care, is not the highest priority. Choice 'B', performing range of motion exercises, is an important part of recovery but not the immediate priority. Choice 'D', using hand rolls or pillows for support, is also a valuable intervention but does not address the most pressing risk of further complications.

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