TEST PREP QUESTIONS AND ANSWERS WITH EXPLANATIONS

In which of the following ways can the nurse promote the sense of taste for an older adult? a. Mix foods together on the dinner tray b. Avoid cologne, air fresheners, or room deodorizers c. Encourage the client to chew food thoroughly d. Discourage the use of salt or seasonings with prepared food ANSWER C: As clients age, their sense of taste may diminish, reducing the joy that comes with eating. A nurse can promote the sense of taste for a client by encouraging him to chew his food thoroughly while eating. This results in longer contact of food with the taste buds and a greater chance of tasting the food. 2. Which of the following is classified as a prerenal condition that affects urinary elimination? a. Nephrotoxic medications b. Pericardial tamponade c. Neurogenic bladder d. Polycystic kidney disease ANSWER B: A prerenal condition is that which causes reduced urinary elimination due to a diminished blood flow to the kidneys. A condition such as cardiac tamponade affects the heart's ability to pump adequate amounts of blood, thereby reducing blood flow to vital organs throughout the body, including the kidneys. 3. A nurse is assessing an African American client for risks of a pressure ulcer. Which of the following best describes what the nurse might find with an early pressure ulcer in this client? a. Skin has a purple/bluish color b. Capillary refill is 1 second c. Skin appears blanched at the pressure site d. Tenting appears when checking skin turgor ANSWER A: When assessing for signs of developing pressure ulcers in a client with dark skin, decreased circulation may not always be readily apparent. For instance, blanching, the red undertones seen in light-skinned clients, will not always be present. Instead, the skin of an early pressure ulcer may develop a purple or bluish color. 4. A term used to refer to generalized wasting of body tissues and malnutrition is called: a. Entropion b. Confabulation c. Induration d. Cachexia S - The Marketplace to Buy and Sell your Study Material ANSWER D: Cachexia is a term used to describe the generalized wasting of body tissues, ill health, and malnutrition that is associated with some chronic diseases. Cachexia involves a loss of fat tissue to protect the bones and joints. Clients with cachexia are at risk of pressure ulcers in addition to complications associated with malnutrition and poor health. 5. Which of the following clients is at a higher risk of developing oral health problems? a. A pregnant client b. A client with diabetes c. A client receiving chemotherapy d. Both b and c ANSWER D: Some clients are at higher risk of developing oral health problems due to changes in the mouth associated with certain diseases, or an inability to provide proper self care and oral hygiene. Diabetic clients may be more likely to develop periodontal disease, gingivitis, or mouth dryness. Clients receiving chemotherapy may have mouth ulcers or gingivitis, leading to further pain and infection. 6. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client? a. Loosen pressure dressings on wounds b. Use assistance to pull a client up in bed c. Check temperature of water used in a sponge bath S - The Marketplace to Buy and Sell your Study Material d. Position the client prone ANSWER C: A nurse can reduce environmental stimuli that can cause discomfort for a client through several interventions. When giving a sponge bath, the nurse can check the temperature of the bath water to ensure it is not too hot to avoid burns, nor too cold, to avoid causing discomfort. Other measures the nurse can perform include lifting clients rather than pulling them up in bed, changing wet dressings, and providing proper positioning while in bed. 7. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition? a. Cracks at the corners of the mouth b. Altered mental status c. Bleeding gums and loose teeth d. Anorexia and diarrhea ANSWER C: A client with a severe vitamin C deficiency has a condition called scurvy. Clients with scurvy are most likely to develop bleeding gums, loose teeth, poor wound healing, and easy bruising. 8. Which of the following interventions should a nurse perform for a female client who is incontinent with impaired skin integrity? a. Turn the client at least every 8 hours b. Apply lotion to the skin before a bath S - The Marketplace to Buy and Sell your Study Material c. Provide perineal care after the client uses the bathroom d. Bathe the client every 3 days ANSWER C: A nurse can help protect the skin integrity of some clients, especially female clients who are incontinent, by performing cares that keep the skin clean and dry. Providing perineal care after the client uses the bathroom promotes good skin integrity by removing excess secretions that could cause odor and infection. 9. A client has fallen asleep in his bed in the hospital. His heart rate is 65 bpm, his muscles are relaxed, and he is difficult to arouse. Which stage of the sleep cycle is this client experiencing?