Nursing Elites

1. A client who practices Orthodox Judaism informs the nurse that he cannot eat certain foods during the Passover holiday. Which of the following actions should the nurse include in the plan of care?

• A. Serve chicken with cream sauce
• B. Avoid serving fish with fins and scales
• C. Provide unleavened bread
• D. Avoid serving foods containing lamb

Correct answer: C

Rationale: During the Passover holiday, individuals practicing Orthodox Judaism adhere to specific dietary restrictions, which include consuming unleavened bread. Providing unleavened bread aligns with the client's religious beliefs and dietary requirements. Choices A, B, and D are incorrect. Serving chicken with cream sauce, avoiding fish with fins and scales, and avoiding foods containing lamb are not directly related to the dietary restrictions observed during the Passover holiday in Orthodox Judaism.

2. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Polyuria
• B. Warm, dry skin
• C. Irritability
• D. Hyperventilation

Correct answer: C

Rationale: Irritability is a common finding in clients with hypoglycemia due to decreased glucose levels in the brain. Polyuria (excessive urination) is not typically associated with hypoglycemia, but rather with hyperglycemia. Warm, dry skin is not a typical finding in hypoglycemia; instead, the skin may be cool and clammy. Hyperventilation is not a common finding in hypoglycemia; instead, shallow breathing or difficulty breathing may occur.

3. How should a healthcare provider monitor a patient with fluid overload?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor input and output
• D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

4. A nurse is assessing a client who has a peripherally inserted central catheter (PICC). Which of the following findings should the nurse report to the provider?

• A. Redness at the insertion site.
• B. Swelling of the arm above the insertion site.
• C. A bruised area around the insertion site.
• D. A temperature of 37.2°C (99°F).

Correct answer: B

Rationale: Swelling of the arm above the insertion site is concerning as it can indicate complications like thrombosis, which require immediate attention. Redness at the insertion site is common and expected in the initial stages. A bruised area around the insertion site may result from the insertion procedure and is usually not alarming unless it worsens or becomes larger. A temperature of 37.2°C (99°F) is within the normal range and is not directly related to PICC complications.

5. A nurse is creating a plan of care for a newly admitted client who has obsessive-compulsive disorder. Which of the following interventions should the nurse take?

• A. Allow the client enough time to perform rituals
• B. Give the client autonomy in scheduling activities
• C. Discourage the client from exploring irrational fears
• D. Provide negative reinforcement for ritualistic behaviors

Correct answer: A

Rationale: The correct intervention for a client with obsessive-compulsive disorder is to allow the client enough time to perform rituals. This helps manage anxiety and stress in individuals with OCD. Allowing time for rituals can provide a sense of control and reduce distress. Choice B, giving the client autonomy in scheduling activities, may not address the core symptoms of OCD related to rituals and compulsions. Choice C, discouraging the client from exploring irrational fears, goes against the principles of exposure therapy, which is a common treatment for OCD. Choice D, providing negative reinforcement for ritualistic behaviors, is not recommended as it can reinforce the behavior rather than help the client manage it.

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