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 client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?

• A. hyperkalemia
• B. hypernatremia
• C. hypokalemia
• D. hypomagnesemia

Correct answer: C

Rationale: When a client is receiving drug therapy with furosemide and digitalis, the nurse should anticipate the development of hypokalemia due to the potassium-wasting effects of furosemide. Hypokalemia can potentiate digitalis toxicity. While hyperkalemia is a concern with some medications, it is not typically associated with furosemide and digitalis. Furosemide can lead to hyponatremia, not hypernatremia, due to its diuretic effect. Hypomagnesemia, though a possible imbalance, is not the most likely to occur in this scenario as furosemide and digitalis are more commonly associated with hypokalemia.

3. A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?

• A. Increase in subcutaneous fat.
• B. Diminished cough reflex.
• C. Long-term memory loss.
• D. Myopia.

Correct answer: B

Rationale: The correct answer is 'Diminished cough reflex.' Diminished cough reflex is a physical finding consistent with normal aging in older adults, which can increase the risk of aspiration and atelectasis. An increase in subcutaneous fat actually raises the risk of pressure ulcers. While long-term memory is typically preserved in aging unless affected by dementia, short-term memory often declines. Myopia (near-sightedness) is common in younger individuals, but presbyopia (far-sightedness) is more common with aging. Additionally, individuals with myopia may experience an improvement in vision as they age.

4. The client has jaundice, elevated liver enzymes, and an elevated serum bilirubin. What color urine does the nurse expect to find?

• A. Pink-tinged
• B. Straw-colored
• C. Clear
• D. Dark amber

Correct answer: D

Rationale: The correct answer is dark amber. In jaundice, the elevated bilirubin levels are excreted in the urine, giving it a dark amber color. Choices A, B, and C are incorrect because in jaundice, the urine typically appears dark amber due to the presence of elevated bilirubin, not pink-tinged, straw-colored, or clear.

5. Which symptom is the client who self-administered an overdose of acetaminophen most likely to exhibit?

• A. Pink frothy sputum
• B. Seizure activity
• C. Jaundiced conjunctiva
• D. Diaphoresis and fever

Correct answer: C

Rationale: When a client self-administers an overdose of acetaminophen, the liver is primarily affected. Jaundiced conjunctiva, which is yellowing of the eyes, is a common symptom of liver damage. Pink frothy sputum is typically associated with conditions like pulmonary edema, not acetaminophen overdose. Seizure activity is not a common symptom of acetaminophen overdose but can be seen in other toxicities. Diaphoresis and fever are more generalized symptoms and not specific to acetaminophen overdose.

Similar Questions