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Jane, an obese hypertensive homemaker, complains of continual hunger and lack of energy. What nursing measure would be most helpful?
- A. Giving her a list of low-calorie foods
- B. Discussing the importance of eating breakfast
- C. Recommending a strict vegetarian diet
- D. Suggesting vitamin supplements
Correct Answer: B
Rationale: Eating breakfast helps regulate metabolism and energy levels throughout the day, reducing hunger and fatigue.
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The old-old population (85 years and older) has an increased risk for frailty. However, old age is just one element of frailty. Identify at least three other assessment findings that contribute to frailty.
- A. Decreased muscle mass
- B. Weight loss
- C. Reduced physical activity
- D. Increasing disability and symptoms
Correct Answer: A
Rationale: Decreased muscle mass, unintentional weight loss, and reduced physical activity are key contributors to frailty in older adults.
Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
Your patient is experiencing exacerbations of systemic lupus erythematosus. What would you expect the physician to prescribe?
- A. Antiemetics.
- B. Corticosteroids.
- C. Antineoplastics.
- D. Antibiotics.
Correct Answer: B
Rationale: Corticosteroids are used to manage SLE flare-ups.
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications.
Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.