Nursing Elites

1. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?

• A. Lower back pain
• B. Shortness of breath
• C. Decreased fetal movement
• D. Nausea and vomiting

Correct answer: A

Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.

2. A nurse is assessing a newborn whose mother had gestational diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Hypertonia
• B. Jitteriness
• C. Acrocyanosis
• D. Generalized petechiae

Correct answer: B

Rationale: Jitteriness is a common sign of hypoglycemia in newborns. Other signs may include irritability, poor feeding, and lethargy. Choice A, Hypertonia, is not typically associated with hypoglycemia but rather with conditions like hypocalcemia. Acrocyanosis (Choice C) is a benign condition characterized by peripheral cyanosis and is not directly linked to hypoglycemia. Generalized petechiae (Choice D) are tiny red or purple spots on the skin due to bleeding and are not specific to hypoglycemia.

3. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take first?

• A. Encourage the client to listen to music
• B. Ask the client what the voices are saying
• C. Provide the client with a distraction
• D. Administer an antipsychotic medication

Correct answer: B

Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.

4. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused
• B. Request a prescription for PRN restraints when the client is wandering
• C. Dim the lighting in the client’s room
• D. Leave one side rail up on the client's bed

Correct answer: D

Rationale: The correct answer is to leave one side rail up on the client's bed. This action can help prevent falls while allowing the client to get up safely when needed, reducing the risk of injury from wandering. Placing the client in seclusion (Choice A) is not appropriate as it can lead to increased agitation and distress. Requesting restraints (Choice B) should be avoided as it can increase the risk of injuries and is not recommended for clients with Alzheimer's. Dimming the lighting (Choice C) may increase confusion and disorientation in clients with Alzheimer's disease.

5. A nurse is completing a dietary assessment for a client who observes kosher dietary practices. Which of the following behaviors should the nurse expect?

• A. Leavened bread may be eaten during Passover
• B. Shellfish is commonly consumed in the diet
• C. Meat and dairy products are eaten separately
• D. Fasting from meat occurs during Hanukkah

Correct answer: C

Rationale: The correct answer is C: 'Meat and dairy products are eaten separately.' In kosher dietary practices, it is essential to keep meat and dairy products separate. Mixing meat and dairy is prohibited, and there are specific guidelines for the preparation and consumption of each. Choices A, B, and D are incorrect. Choice A is wrong because leavened bread is not eaten during Passover in kosher practices. Choice B is incorrect as shellfish is not consumed in a kosher diet. Choice D is also inaccurate as fasting from meat does not occur during Hanukkah in kosher dietary practices.

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