Nursing Elites

1. A client with an acute myocardial infarction is concerned about extreme fatigue. What is the best strategy to promote independence in self-care?

• A. Instruct the client to limit all activity until fully rested
• B. Encourage the client to gradually resume self-care tasks with rest periods
• C. Assign assistive personnel to complete self-care tasks
• D. Ask the client's family to assist with self-care

Correct answer: B

Rationale: Encouraging the client to gradually resume self-care tasks with rest periods is the best strategy to promote independence in self-care for a client with acute myocardial infarction. This approach allows the client to regain independence while considering the need for rest to prevent overexertion. Instructing the client to limit all activity until fully rested (Choice A) may hinder independence by promoting inactivity. Assigning assistive personnel to complete self-care tasks (Choice C) does not promote the client's independence. Asking the client's family to assist with self-care (Choice D) may not foster the client's self-reliance and may not always be feasible.

2. What is the primary action the nurse should take first for a client with a pressure ulcer who has a serum albumin level of 3 g/dL?

• A. Increase the protein intake in the diet
• B. Consult with a dietitian to create a high-protein diet
• C. Increase the IV fluid infusion rate
• D. Administer a protein supplement

Correct answer: B

Rationale: The correct answer is to consult with a dietitian to create a high-protein diet. A serum albumin level of 3 g/dL indicates hypoalbuminemia, which can impair wound healing. Consulting with a dietitian to optimize the client's protein intake is crucial in promoting wound healing for pressure ulcers. Increasing the protein intake in the diet (Choice A) may not be sufficient without proper guidance from a dietitian. Increasing the IV fluid infusion rate (Choice C) is not directly related to addressing the protein deficiency. Administering a protein supplement (Choice D) should be guided by a healthcare professional's recommendation after consulting with a dietitian.

3. Which of the following interventions is most appropriate for a client with left-leg weakness who is learning to use a cane?

• A. Maintain two points of support on the floor at all times
• B. Use the cane on the weak side of the body
• C. Advance the cane and the strong leg simultaneously
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The most appropriate intervention for a client with left-leg weakness learning to use a cane is to maintain two points of support on the floor at all times. This ensures stability and helps distribute weight evenly between the legs, reducing the risk of falls. Using the cane on the weak side of the body (Choice B) may not provide adequate support. Advancing the cane and the strong leg simultaneously (Choice C) can lead to imbalance and increases the risk of falls. Advancing the cane too far with each step (Choice D) can also compromise balance and stability.

4. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

• A. Serum glucose level.
• B. Serum calcium level.
• C. Lymphocyte count.
• D. Serum potassium level.

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is an excess production of cortisol, leading to hyperglycemia. This results in an increase in serum glucose levels. Choices B, C, and D are incorrect because Cushing's disease does not directly affect serum calcium levels, lymphocyte count, or serum potassium levels.

5. What is an essential nursing intervention for a client experiencing delirium?

• A. Control behavioral symptoms with low-dose psychotropics
• B. Identify the underlying causative condition
• C. Increase environmental stimulation
• D. Administer antipsychotic medication

Correct answer: B

Rationale: The correct answer is B - 'Identify the underlying causative condition.' When a client is experiencing delirium, it is crucial to determine the root cause of this acute change in mental status. This can involve a thorough assessment to identify any medical conditions, medications, infections, or environmental factors that may be contributing to the delirium. By pinpointing the underlying cause, appropriate interventions can be implemented to address the specific issue. Choices A, C, and D are incorrect because controlling behavioral symptoms with low-dose psychotropics, increasing environmental stimulation, and administering antipsychotic medication do not target the primary need of identifying and addressing the causative condition of delirium.

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