QUESTION COMPENDIUM WITH CORRECT
SOLUTIONS
◉Which nutritional assessment data should the nurse collect to best
reflect total muscle mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
C) Triceps skin fold thickness.
D) Upper arm circumference. Answer: D) Upper arm circumference
Upper arm circumference (D) is an indirect measure of muscle mass.
(A and B) do not distinguish between fat (adipose) and muscularity.
(C) is a measure of body fat.
◉An older client who is a resident in a long term care facility has
been bedridden for a week. Which finding should the nurse identify
as a client risk factor for pressure ulcers?
A) Generalized dry skin.
,B) Localized dry skin on lower extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and skin fold regions Answer: D)
Rashes in the axillary, groin, and skin fold regions
Immobility, constant contact with bed clothing, and excessive heat
and moisture in areas where air flow is limited contributes to
bacterial and fungal growth, which increases the risk for rashes (D),
skin breakdown, and the development of pressure ulcers. (A, B, and
C) do not address the concepts of inflammation and tissue integrity
◉During a visit to the outpatient clinic, the nurse assesses a client
with severe osteoarthritis using a goniometer. Which finding should
the nurse expect to measure?
A) Adequate venous blood flow to the lower extremities.
B) Estimated amount of body fat by an underarm skinfold.
C) Degree of flexion and extension of the client's knee joint.
D) Change in the circumference of the joint in centimeters Answer:
C) Degree of flexion and extension of the client's knee joint
The goniometer is a two-piece ruler that is jointed in the middle
with a protractor-type measuring device that is placed over a joint
as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor (C). A doppler is used to
,measure blood flow (A). Calipers are used to measure body fat (B). A
tape measure is used to measure circumference of body parts (D).
◉The healthcare provider prescribes 1,000 ml of Ringer's Lactate
with 30 Units of Pitocin to run in over 4 hours for a client who has
just delivered a 10 pound infant by cesarean section. The tubing has
been changed to a 20 gtt/ml administration set. The nurse plans to
set the flow rate at how many gtt/min?
A) 42 gtt/min.
B) 83 gtt/min.
C) 125 gtt/min.
D) 250 gtt/min Answer: B. 83 gtt/min
◉An Arab-American woman, who is a devout traditional Muslim,
lives with her married son's family, which includes several adult
children and their children. What is the best plan to obtain consent
for surgery for this client?
A) Obtain an interpreter to explain the procedure to the client.
B) Encourage the client to make her own decision regarding surgery.
C) Ask the family members to provide an interpretation of the
surgeon's explanation to the client.
, D) Tell the surgeon that the son will decide after explanation of the
proposed surgery is provided. Answer: D) Tell the surgeon that the
son will decide after explanation of the proposed surgery is
provided
Traditional Muslim women live in a patriarchal family where
decisions are made by men. Most likely, the son will make the
decision for his mother, so (D) provides the surgeon with culturally
sensitive information. (A) may be necessary if a language barrier
exists, but the son is the patriarch in the client's family at this time. It
is culturally insensitive to encourage the woman to go against her
religious and cultural worldview, as in (B). Family members are
more likely to misinterpret medical information, but the son should
be the primary decision-maker for his mother (C).
◉In developing a plan of care for a client with dementia, the nurse
should remember that confusion in the elderly
A) is to be expected, and progresses with age.
B) often follows relocation to new surroundings.
C) is a result of irreversible brain pathology.
D) can be prevented with adequate sleep Answer: B) often follows
relocation to new surroundings