Nursing Elites

1. A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?

• A. Risk for injury related to exophthalmos
• B. Impaired social interaction related to emotional lability
• C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
• D. Activity intolerance related to fatigue

Correct answer: D

Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.

2. A nurse is reinforcing teaching with a client who has neutropenia as a result of radiation therapy for the treatment of lung cancer. Which of the following should the nurse plan to include in the teaching?

• A. Increase fluid intake by drinking bottled water.
• B. A salad bar is a healthy choice when dining out.
• C. Soft-boiled eggs are an appropriate source of protein.
• D. Eating at buffets is a good choice to increase caloric intake.

Correct answer: A

Rationale: Clients with neutropenia should avoid foods that may be contaminated to prevent infections. Increasing fluid intake is important to stay hydrated, but it's crucial to use safe sources like bottled water to reduce the risk of infection. Choices B, C, and D are not appropriate for a client with neutropenia. Salad bars may contain raw or unwashed produce, soft-boiled eggs may carry a risk of contamination, and buffets may have food items that are not recommended for someone with neutropenia.

3. An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next?

• A. Add a thickening agent to the fluids
• B. Check the client's gag reflex
• C. Feed the client only solid foods
• D. Increase the rate of intravenous fluids

Correct answer: B

Rationale: Checking the client's gag reflex is the appropriate action in this scenario. It helps assess the client's ability to swallow safely without the risk of aspiration. Adding a thickening agent to the fluids (Choice A) may be considered later if swallowing difficulties persist. Feeding the client only solid foods (Choice C) can increase the risk of aspiration in this case, and increasing the rate of intravenous fluids (Choice D) does not address the swallowing concern.

4. Which of these nursing assessments would be the highest priority for a client at risk for aspiration pneumonia?

• A. Assessing the client's level of consciousness
• B. Monitoring the client's oxygen saturation
• C. Checking the client's gag reflex before eating or drinking
• D. Monitoring the client's intake and output

Correct answer: C

Rationale: Checking the client's gag reflex before eating or drinking is the highest priority for a client at risk for aspiration pneumonia. Aspiration pneumonia can occur when food, liquids, or saliva are inhaled into the lungs, leading to inflammation or infection. Checking the gag reflex helps prevent the aspiration of substances into the lungs. Assessing the client's level of consciousness (Choice A) is important but not as immediately critical as checking the gag reflex. Monitoring oxygen saturation (Choice B) is essential for respiratory assessment but does not directly prevent aspiration. Monitoring intake and output (Choice D) is important for overall client management but does not specifically address the risk of aspiration pneumonia.

5. Discharge instructions for a client taking alprazolam (Xanax) should include which of the following?

• A. Sedative hypnotics are effective analgesics
• B. Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares
• C. Caffeine beverages can increase the effect of sedative hypnotics
• D. Avoidance of excessive exercise and high temperature is recommended

Correct answer: B

Rationale: The correct answer is B. Alprazolam should not be stopped abruptly as it can cause rebound insomnia and nightmares; gradual tapering is necessary. Choice A is incorrect as sedative hypnotics are not primarily used as analgesics. Choice C is incorrect as caffeine can decrease the effects of sedative hypnotics rather than increase them. Choice D is incorrect as there is no specific recommendation to avoid excessive exercise or high temperature related to alprazolam use.

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