Nokea
An 82-year-old woman is being admitted to a long-term care facility. Her assigned nurse completes a full assessment, including calculating the risk for skin breakdown based on the Braden Scale. To determine a Braden Scale score, the nurse evaluates all of the following EXCEPT
- A. nutritional status.
- B. sensory perception.
- C. past history of skin breakdown.
- D. activity level.
Correct Answer: C
Rationale: The Braden Scale assesses sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Past history of skin breakdown is not a scored category.
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An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Activities fostering self-identity address the underlying issues of low self-esteem and perfectionism common in anorexia nervosa.
An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
- A. tunneling.
- B. dehiscence.
- C. undermining.
- D. evisceration.
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A. A 28-year-old with a history of alcohol use during the pregnancy
- B. A 24-year-old with a history of diabetes mellitus
- C. A 30-year-old with a history of smoking during the pregnancy
- D. A 32-year-old with a history of pregnancy-induced hypertension
Correct Answer: B
Rationale: Maternal diabetes increases the risk of respiratory distress syndrome in infants due to impaired surfactant production from fetal hyperglycemia.
In order to ensure adequate protein intake during pregnancy, how many additional grams of protein should the woman ingest daily during the second half of the pregnancy? Report your answer using a whole number.
Correct Answer: 25
Rationale: Pregnant women need an additional 25 grams of protein daily in the second half of pregnancy to support fetal growth and maternal health.
The schizophrenic client has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: An RN has the authority to initiate seclusion based on clinical judgment.