Nursing Elites

1. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

2. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

• A. Lamb
• B. Poultry
• C. Tuna
• D. Beef

Correct answer: A

Rationale: The correct answer is A: Lamb. Lamb is high in saturated fat, which is linked to an increased risk of developing cancer. Choice B (Poultry) is a lean protein source and is not associated with an increased cancer risk. Choice C (Tuna) is a good source of omega-3 fatty acids, which have anti-inflammatory properties that may reduce cancer risk. Choice D (Beef) is also high in saturated fat like lamb, making it a poor choice for cancer prevention.

3. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

• A. Amnesia
• B. Hypervigilance
• C. Hallucinations
• D. Severe agitation

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

4. What should be included in dietary teaching for a client with chronic kidney disease?

• A. Increase potassium-rich foods in the diet
• B. Limit potassium and phosphorus intake
• C. Increase intake of protein-rich foods
• D. Increase fluid intake to prevent dehydration

Correct answer: B

Rationale: The correct answer is to limit potassium and phosphorus intake for a client with chronic kidney disease. Excessive potassium and phosphorus can be harmful to individuals with compromised kidney function. Option A is incorrect because increasing potassium-rich foods can exacerbate hyperkalemia in individuals with kidney disease. Option C may not be ideal as excessive protein intake can put extra strain on the kidneys. Option D is not the priority; while adequate fluid intake is important, it is not the primary focus when teaching dietary considerations for chronic kidney disease.

5. What is the best dietary recommendation for a patient with chronic kidney disease?

• A. Low-protein diet
• B. High-protein diet
• C. Low-sodium diet
• D. High-sodium diet

Correct answer: A

Rationale: The correct answer is a low-protein diet for a patient with chronic kidney disease. In chronic kidney disease, the kidneys may have difficulty filtering waste products from protein metabolism, leading to a buildup of toxins in the body. Therefore, reducing protein intake can help lessen the workload on the kidneys. Choices B, C, and D are incorrect. A high-protein diet would increase the workload on the kidneys, while a low-sodium diet is beneficial for conditions like hypertension or heart failure but not specifically targeted for chronic kidney disease. A high-sodium diet can worsen fluid retention and hypertension in patients with kidney disease.

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