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. Which nutrient is critical for wound healing and immune function?

• A. Vitamin B12
• B. Vitamin C
• C. Vitamin D
• D. Vitamin K

Correct answer: B

Rationale: Vitamin C is essential for collagen formation and immune function.

3. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

4. A nurse at a health fair is assessing the weight status of four clients. Which of the following clients is classified as overweight?

• A. A female client who has a body mass index of 24
• B. A male client who has a body mass index of 29
• C. A female client who has a waist circumference of 101.6 cm (40 in)
• D. A male client who has a waist circumference of 96.52 cm (38 in)

Correct answer: B

Rationale: A body mass index (BMI) of 25 or higher is classified as overweight. Choice B, a male client with a BMI of 29, falls into the overweight category. Choice A, a female client with a BMI of 24, is within the normal range. Choices C and D provide information on waist circumference, which is not sufficient to determine if a client is overweight or not, as waist circumference alone does not provide the overall picture of weight status compared to BMI.

5. In alcoholic patient, the nurse knows that the vitamin deficient to these types of clients that leads to psychoses is:

• A. Thiamine C. Niacin
• B. Vitamin C D. Vitamin A
• C.
• D.

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

Similar Questions