Nursing Elites

1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. Within normal limits, so a weight-reduction diet is unnecessary.
• B. Lower than normal, so education about nutrient-dense foods is needed.
• C. Indicating obesity because the BMI is 35.
• D. Indicating overweight status because the BMI is 27.

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.

2. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

• A. Sore throat
• B. Vertigo
• C. Fever
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

3. The nurse is caring for a client and wants to assess the neurologic function. Which of the following will give the most information?

• A. Level of consciousness
• B. Doll's eye reflex
• C. Babinski reflex
• D. Reaction to painful stimuli

Correct answer: A

Rationale: The correct answer is 'Level of consciousness.' Assessing the client's level of consciousness provides crucial information about their neurologic function, including subtle changes in verbal ability, orientation, and responsiveness to commands. Doll's eye reflex is a specific eye movement test used in neurologic assessments but may not provide as much comprehensive information as the client's overall consciousness level. The Babinski reflex is a test used to assess specific spinal cord function rather than overall neurologic function. Reaction to painful stimuli provides information about sensory function and pain response but may not offer as much insight into the client's neurologic status as assessing their level of consciousness.

4. One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:

• A. cor pulmonale.
• B. atelectasis.
• C. pulmonary embolism.
• D. cardiac tamponade.

Correct answer: B

Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.

5. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. within normal limits, so a weight-reduction diet is unnecessary
• B. lower than normal, so education about nutrient-dense foods is needed
• C. indicating obesity because the BMI is 35
• D. indicating overweight status because the BMI is 27

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Choices A, B, and D are incorrect because the client's BMI is above 30, which falls under the obesity category. Therefore, a weight-reduction diet and increased physical activity are necessary to address the client's weight status and promote overall health.

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