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WorksheetsExam 3 cont'd
Total questions: 53
Worksheet time: 27mins
Case: Mrs. Peterson, 78, reports fatigue and dizziness. She eats mostly toast and coffee. Question: Which nursing diagnosis is most appropriate?
Risk for unstable blood glucose
Imbalanced nutrition: less than body requirements
Fatigue related to anemia
Activity intolerance
Case: Mr. Larkin, 63, with heart disease, consumes sausage, cheese, and pastries daily.
Sausage
Cheese
Butter
Whole grain bread
Case: A nurse is teaching a group of older adults about preventing constipation.
Which suggestion is most appropriate?
Increase dietary fiber intake.
Limit fluid consumption.
Reduce physical activity.
Eat fewer fruits and vegetables.
Ms. Hines, 55, wants to reduce her LDL cholesterol. Which food choice supports her goal?
Egg yolks
Avocado
Whole milk
Fried chicken
Case: A nurse prepares a meal tray for a client on a cardiac diet. What food would the nurse question?
Boiled potatoes
Skinless turkey breast
Bacon strips
Steamed broccoli
Case: Mrs. Allen, 91, has poor dentition and difficulty chewing. What diet is most appropriate?
Full liquid
Soft mechanical
Diabetic
High-fiber
Mr. James, 47, asks about the purpose of carbohydrates. Which is the best explanation?
They are structural components of cells.
They help digest fats.
They are the body's primary energy source.
They are used to make hormones.
Case: A client on a clear liquid diet asks what they can eat. What item should be included?
Chicken broth
Yogurt
Mashed potatoes
Milk
Case: A nurse assists a Parkinson’s client with feeding. What technique is most important?
Serve meals with utensils already in hand
Offer finger foods for easier control
Position upright and assess swallowing
Place food far from dominant hand
Case: Ms. Taylor, 73, eats only toast and tea daily. Question: Which nutrient is she most likely deficient in?
Iron
Fiber
Protein
Vitamin C
Case: A client asks why vitamins are important. Question: Which statement is most correct?
They help regulate body processes.
They provide energy directly.
They are only needed in childhood.
They prevent dehydration.
Case: A diabetic client’s A1C is high. Which recommendation is most appropriate?
Increase fruit juice
Reduce complex carbohydrates
Eat frequent small meals with consistent carb levels
Avoid fiber
Case: Mr. Robles consumes soda, chips, and donuts for lunch. What is the best nursing diagnosis?
Risk for aspiration
Readiness for enhanced health literacy
Imbalanced nutrition: more than body requirements
Altered thought processes
Case: A client’s mid-arm circumference and triceps skinfold are below normal. What does this most suggest?
Dehydration
Iron deficiency
Muscle wasting and malnutrition
Obesity
Case: A vegan client asks about B12. Which recommendation is best?
Eat tofu
Take a B12 supplement or consume fortified foods
Add red meat occasionally
Increase green leafy vegetables
Case: A nurse serves a meal to a visually impaired client. What strategy is most helpful?
Describe plate as a clock
Cut all food in advance
Spoon-feed entire meal
Avoid distractions
Case: A nurse documents intake after meal service. What data is most important?
Tray number
Food temperature
Case: Mr. Griffin refuses his diabetic meal and says it's bland. What is the best action?
Notify physician
Encourage water intake
Offer permitted substitutions
Document and skip the meal
An 82-year-old client has decreased sense of taste. What effect does this most likely have?
Overhydration
Nutrient overabsorption
Decreased appetite and intake
Hyperkalemia
A client needs a high-protein soft diet. Which meal is most appropriate?
Steamed broccoli and rice
Scrambled eggs and mashed potatoes
Toast with peanut butter and banana
Milkshake and crackers
Case: A nurse teaches about MyPlate. Question: What is the best takeaway?
Limit dairy to once weekly
Make half the plate fruits and vegetables
Avoid protein in breakfast
Focus on processed grains
Case: Ms. Landon is malnourished and bedbound. What lab should the nurse monitor?
Creatinine
Albumin
Troponin
Hemoglobin A1C
Case: A client is ordered a full liquid diet. What item is acceptable?
Gelatin
Tea
Vanilla pudding
Toast
Mr. Braun needs protein complementation. What is the best food combo?
Rice and beans
Broccoli and tofu
Yogurt and apples
Egg and toast
A nurse provides oral care to a client with poor intake. Why is this important?
Prevents cavities
Stimulates salivation and appetite
Helps absorb nutrients
Prevents diarrhea
Case: Ms. Nolan, 81, bedbound with fragile skin, is left in one position for 5 hours.
Risk for falls
Impaired skin integrity
Risk for disuse syndrome
Risk for infection
What goal does this action support?
Speed of movement
Client independence
Protection of skin and nurse’s back
Preservation of IV lines
Case: Mr. Henry, 84, slides down in bed after being positioned at 60°. What is the best explanation?
Poor mattress quality
Hip flexion reflex
Shearing forces from gravity in high Fowler's position
Weak quadriceps
Assessment that confirms correct position is:
Auscultation
Inspection
Palpation
Percussion
What risk does this create if prolonged?
Pressure ulcer on sacrum
Hip dislocation
Joint contracture
Sciatic nerve injury
Case: Ms. Harris, 66, has hemiplegia. Which positioning device is most important to prevent external rotation of her leg?
Hand roll
Footboard
Trochanter roll
Cradle
Case: A nurse transfers a client using a gait belt. Which technique is most correct?
Stand to side of client and hold under arms
Tighten gait belt above diaphragm
Use broad stance and pivot on back foot
Keep knees straight during transfer
Case: Mr. Lane, 79, has severe kyphosis and prefers to sit upright in bed. What is the most appropriate position?
Prone
Supine
High Fowler’s
Trendelenburg
A nurse is teaching new staff about body alignment. Which client position is least aligned?
Supine with head and feet elevated equally
Lateral with hips stacked and pillow between legs
High Fowler’s with legs flat and trunk flexed
Sims’ with arms folded under chest
Case: A nurse prepares to move a paralyzed client. What is the first safety measure?
Lock bed wheels
Elevate head of bed
Raise bed to working height
Remove catheter bag
Case: A client uses a trapeze bar. Question: What outcome does this promote?
Pressure relief
Passive movement
Upper-body strength and independence
Traction support
A client's heels are reddened. What device should the nurse apply?
Trochanter roll
Pillow under knees
Pillow under calves with heels floating
Cradle
Case: A client is confused and tries to get out of bed. What intervention best reduces fall risk?
Raise all side rails
Leave bed in high position
Use a bed alarm
Apply wrist restraints
Case: Mrs. Goodwin, 93, cannot raise herself from bed. What tool promotes independence?
Trapeze bar
Footboard
Gel overlay
Cradle
When is this device best used?
Client with no upper body strength
Client with paraplegia
Confused, ambulatory client
Sedated ICU patient
Case: A nurse is transferring a client post-stroke. Which principle is most important?
Move client toward strong side
Use arms for support
Pivot toward weak side
Place wheelchair behind client
Case: Ms. Shelby, 87, needs support to keep blankets off her feet.
Cradle
Gel pad
Footboard
Hand roll
What is the nurse’s primary responsibility?
Push device from the front
Allow one staff member to operate
Ensure all straps are secure
Keep arms inside the sling
A nurse is evaluating a client in prone position.
Shoulder dislocation
Airway compromise
Skin turgor
Knee flexion
What risk is most associated?
Pulmonary embolism
Joint contracture
Hypoglycemia
Constipation
A client must be turned as a unit. What is this method called?
Pivot turn
Quarter roll
The nurse finds a client in the supine position with feet plantar flexed. What should the nurse implement?
Trochanter roll
Egg crate
Footboard
Cradle
Case: Mr. Hill, 66, is lying with twisted spine in lateral position. What is the most effective intervention?
Move client to prone
Insert pillow under upper leg and shoulders
Lower bed for comfort
Give pain meds
The best position for a client immediately after being assisted from chair to bed is:
Supine position
Prone position
High Fowler's position
Trendelenburg position
What is the best position for a client with activity intolerance post-movement?
Supine, flat
Semi-Fowler’s with supported joints
High Fowler’s
Trendelenburg
What is the most therapeutic explanation?
To give you exercise.
So you don’t get bored.
To prevent skin breakdown and keep blood moving.
Because it’s required by policy.
The most appropriate diagnosis is:
Pneumothorax
Pneumonia
Congestive heart failure
Pulmonary embolism
The step in SKILL 30-1 that ensures client dignity and effectiveness is:
Providing privacy and explaining the procedure to the client
Ignoring the client's preferences
Rushing through the procedure
Skipping hand hygiene before the procedure
