Nursing Elites

1. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetic Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

2. A client asks the nurse what risk factors increase the chances of getting skin cancer. The risk factors include all except:

• A. light or fair complexion.
• B. exposure to sun for extended periods of time.
• C. certain diet and foods.
• D. history of bad sunburns.

Correct answer: C

Rationale: The correct answer is 'certain diet and foods.' Risk factors that increase the chances of getting skin cancer include having a light or fair complexion, a history of bad sunburns, personal or family history of skin cancer, outdoor activities with sun exposure, exposure to X-rays or radiation, exposure to certain chemicals, repeated trauma or injury resulting in scars, age over 50, male gender, and living in specific geographic locations. These factors can contribute to the development of skin cancer. Avoiding exposure to the sun, using protective clothing and sunscreen, and regular skin inspections are key preventive measures. Choice C, 'certain diet and foods,' is incorrect as diet is not a primary risk factor for skin cancer. Options A, B, and D are all valid risk factors associated with an increased risk of developing skin cancer.

3. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

4. A nurse is preparing to screen a client's vision with the use of a Snellen chart. The nurse uses which technique?

• A. Tests the right eye, then tests the left eye, and finally tests both eyes together
• B. Assesses both eyes together, then assesses the right and left eyes separately
• C. Asks the client to stand 40 feet from the chart and read the largest line on the chart
• D. Asks the client to stand 40 feet from the chart and read the line that can be read 200 feet away by someone with unimpaired vision

Correct answer: A

Rationale: To test visual acuity with the use of a Snellen chart, the nurse places the chart in a well-lit spot at the client's eye level, with the client positioned exactly 20 feet from the chart. The client shields one eye at a time with an opaque card during the test. After testing each eye separately, both eyes are assessed together. The client is asked to read the smallest line of letters visible and encouraged to read the next smallest line as well. Therefore, option A is correct as it describes the correct technique of testing one eye at a time before assessing both eyes together. Option B is incorrect as it assesses both eyes together first, which is not the standard procedure. Options C and D are incorrect as they suggest standing 40 feet from the chart, which contradicts the standard distance of 20 feet for a Snellen chart test.

5. A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?

• A. Notifying the healthcare provider
• B. Stopping the oxytocin infusion
• C. Checking the woman's blood pressure and pulse
• D. Increasing the intravenous (IV) rate of the nonadditive solution

Correct answer: B

Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.

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