Nursing Elites

1. A nurse is reinforcing teaching with a client who has fluid volume deficit about selecting foods that have a high water content. The nurse should include that which of the following raw foods contains the highest amount of water per 1 cup serving?

• A. Cherry tomatoes
• B. Potatoes
• C. Spinach
• D. Cucumber slices

Correct answer: D

Rationale: The correct answer is D, cucumber slices. Cucumbers have the highest water content per 1 cup serving among raw vegetables, making them an excellent choice for a client with fluid volume deficit. Cherry tomatoes (choice A), potatoes (choice B), and spinach (choice C) do not have as high water content as cucumbers and therefore are not the best choice for increasing fluid intake.

2. The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors?

• A. Sleep disturbances
• B. Concomitant depression
• C. Agitation and assaultiveness
• D. Confusion and withdrawal

Correct answer: C

Rationale: The correct answer is C: Agitation and assaultiveness. Risperidone is commonly prescribed for clients with Alzheimer's disease to reduce symptoms of agitation and aggressive behavior. This medication helps in managing challenging behaviors often seen in individuals with Alzheimer's. Choice A, sleep disturbances, is incorrect as risperidone is not primarily indicated for treating sleep issues in Alzheimer's patients. Choice B, concomitant depression, is also incorrect as risperidone is not the first-line treatment for depression in Alzheimer's disease. Choice D, confusion and withdrawal, is incorrect as risperidone does not directly target these symptoms in Alzheimer's patients.

3. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

4. A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

• A. Place the client in a prone position
• B. Place the client in a 30-degree lateral position
• C. Encourage the client to reposition every 4 hours
• D. Place the client in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: Place the client in a 30-degree lateral position. Positioning the client laterally reduces pressure on bony prominences, improving circulation and helping prevent pressure injuries. Placing the client in a prone position (choice A) increases pressure on the bony prominences, raising the risk of pressure injuries. Similarly, placing the client in a high Fowler's position (choice D) can also increase pressure on certain areas. While encouraging the client to reposition every 4 hours (choice C) is important, the specific lateral positioning is more beneficial in preventing pressure injuries.

5. How should a healthcare professional respond to a patient with diabetic ketoacidosis (DKA)?

• A. Administer insulin
• B. Administer IV fluids
• C. Monitor blood glucose
• D. All of the above

Correct answer: D

Rationale: When managing a patient with diabetic ketoacidosis (DKA), it is crucial to administer insulin to lower blood sugar levels, administer IV fluids to correct dehydration and electrolyte imbalances, and monitor blood glucose levels regularly to ensure they are within the target range. Therefore, all of the above options are essential components of the comprehensive treatment plan for DKA. Administering insulin alone may lower blood sugar levels but will not address the fluid and electrolyte imbalances seen in DKA. Similarly, administering IV fluids alone may help with dehydration but will not address the high blood sugar levels or the need for insulin. Monitoring blood glucose alone is not sufficient to treat DKA; it must be accompanied by appropriate interventions to address the underlying causes and complications of the condition.

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