Nursing Elites

1. Interacting with the patient and their family to obtain subjective information is part of which of the following steps in determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: D

Rationale: The correct answer is D, Assessment. In the nursing process, assessment is the first step where nurses gather subjective and objective data to understand the patient's needs. Interacting with the patient and their family to obtain subjective information is crucial in this phase. Choice A, Evaluation, comes later in the process and involves judging the effectiveness of the care provided. Choice B, Planning, is where the nurse develops a plan of care based on the assessment findings. Choice C, Implementation, is the phase where the nursing care plan is put into action.

2. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this scenario. Cellulitis is a bacterial skin infection that requires prompt treatment with antibiotics to prevent its spread and potential complications. While warm moist packs and elevation can be beneficial as adjunct measures, they are not the initial priority. Teaching about skin and foot care is important, but it can be addressed after stabilizing the acute condition with antibiotics.

3. Which signs/symptoms would the nurse expect to find in the client diagnosed with an insulinoma?

• A. Nervousness, jitteriness, and diaphoresis
• B. Flushed skin, dry mouth, and tented skin turgor
• C. Polyuria, polydipsia, polyphagia
• D. Hypertension, tachycardia, and feeling hot

Correct answer: A

Rationale: Corrected Rationale: Insulinomas lead to excessive insulin production, causing hypoglycemia. Symptoms of hypoglycemia include nervousness, jitteriness, and diaphoresis. These symptoms result from the low blood sugar levels. Flushed skin, dry mouth, and tented skin turgor (choice B) are more indicative of dehydration. Polyuria, polydipsia, and polyphagia (choice C) are classic symptoms of diabetes mellitus, not insulinomas. Hypertension, tachycardia, and feeling hot (choice D) are not typical symptoms of insulinomas.

4. For a patient with a history of liver disease, which type of diet is most appropriate?

• A. High-protein
• B. High-carbohydrate
• C. Low-protein
• D. Low-fat

Correct answer: D

Rationale: A low-fat diet is the most appropriate for a patient with a history of liver disease. This diet helps reduce liver stress and manage symptoms associated with liver disease. High-protein and high-carbohydrate diets can strain the liver and worsen the condition. A low-protein diet may be necessary in cases of liver disease with hepatic encephalopathy, but in general, a low-fat diet is recommended to support liver function and overall health.

5. In assessing the client's chest, which position best shows chest expansion as well as its movements?

• A. Sitting
• B. Prone
• C. Sidelying
• D. Supine

Correct answer: A

Rationale: The position that best shows chest expansion as well as its movements is when the client is sitting. When the client is seated, their chest is in an optimal position for observing the full range of chest expansion during breathing. This position allows for easy visualization of chest movements and expansion as the client breathes in and out, providing a comprehensive assessment of respiratory function. Choice B (Prone) and Choice D (Supine) involve positions where the chest's movements and expansion are less visible and may not provide an accurate representation of respiratory function. Choice C (Sidelying) can also limit the visibility of chest expansion compared to the sitting position.

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