Nursing Elites

1. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions for a client with fluid volume deficit include monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. Monitoring vital signs helps in early detection of changes, daily weighing can indicate fluid retention or loss, and skin turgor assessment is a reliable indicator of hydration status. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and should not be included in the plan of care for this specific condition.

2. A patient with diabetes should be advised to avoid which type of carbohydrate?

• A. Simple carbohydrates
• B. Complex carbohydrates
• C. Fiber-rich carbohydrates
• D. All carbohydrates

Correct answer: A

Rationale: The correct answer is A: Simple carbohydrates. Simple carbohydrates can cause rapid spikes in blood glucose levels, which can be problematic for patients with diabetes. These carbohydrates are quickly broken down and absorbed by the body, leading to sharp increases in blood sugar levels. In contrast, complex carbohydrates and fiber-rich carbohydrates are generally better choices for individuals with diabetes because they are digested more slowly, resulting in a more gradual rise in blood glucose levels. Choice B, complex carbohydrates, are a better option for diabetic patients compared to simple carbohydrates. Choice C, fiber-rich carbohydrates, can also be beneficial for individuals with diabetes as they help in regulating blood sugar levels. Choice D, all carbohydrates, is too broad of a statement as not all carbohydrates have the same impact on blood glucose levels.

3. When assessing the integumentary system of a client with anorexia nervosa, which finding would support the diagnosis?

• A. Preoccupation with calories
• B. Thick body hair
• C. Sore tongue
• D. Dry, brittle hair

Correct answer: D

Rationale: Dry, brittle hair is a common sign of malnutrition, often seen in clients with anorexia nervosa. In anorexia nervosa, the body lacks essential nutrients due to severe calorie restriction, leading to dryness and brittleness of the hair. Choices A, B, and C are less likely to directly indicate anorexia nervosa. Preoccupation with calories can be a behavioral symptom, thick body hair is not a typical finding associated with anorexia nervosa, and a sore tongue is more commonly related to nutritional deficiencies like vitamin deficiencies rather than anorexia nervosa.

4. After a pericardiocentesis, what interventions should the nurse implement?

• A. Monitor vital signs every 15 minutes for the first hour
• B. Evaluate the client’s cardiac rhythm
• C. Record the amount of fluid removed as output
• D. All of the above

Correct answer: D

Rationale: After a pericardiocentesis, the nurse should implement multiple interventions to monitor the client's condition closely. Monitoring vital signs every 15 minutes for the first hour is crucial to detect any immediate changes that may indicate complications. Evaluating the client's cardiac rhythm is important to identify any arrhythmias that may occur due to the procedure. Recording the amount of fluid removed is essential to calculate fluid balance and ensure accurate monitoring of the client's status. Therefore, all the interventions mentioned are necessary to detect and manage any potential issues post-pericardiocentesis. Choices A, B, and C are all essential components of post-procedural care and should be implemented to ensure the client's safety and well-being.

5. A client is admitted to the hospital with the diagnosis of a right-sided brain attack (CVA). The client is right-handed. Which task will be most difficult for this client?

• A. Eating meals
• B. Writing letters
• C. Combing the hair
• D. Dressing every morning

Correct answer: B

Rationale: The correct answer is B: Writing letters. Writing requires fine motor skills, which are often impaired in a right-handed person with a right-sided CVA. Eating meals (choice A) involves gross motor skills and can be adapted for easier handling. Combing the hair (choice C) and dressing every morning (choice D) also require fine motor skills, but they are generally less complex and demanding than writing letters.

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