Nursing Elites

1. During the detoxification stage, it is a priority for the nurse to:

• A. teach skills to recognize and respond to health threatening situations
• B. increase the client’s awareness of unsatisfactory protective behaviors
• C. implement behavior modification
• D. promote homeostasis and minimize the client’s withdrawal symptoms

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. A paranoid client refuses to eat telling you that you poisoned his food. The best intervention to this client is:

• A. Taste the food in front of him and tell him that the food is not poisoned
• B. Offer other types of food until the client eats
• C. Simply state that the food is not poisoned
• D. Offer sealed foods

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

3. A nurse is planning care for a client who has ascites secondary to liver disease. Which of the following interventions should the nurse include in the plan of care?

• A. Reduce complex carbohydrates to 30% of total calories.
• B. Restrict protein intake to less than 0.8 g/kg/day.
• C. Decrease daily caloric intake by 20%.
• D. Limit sodium to 2000 mg or less per day.

Correct answer: D

Rationale: The correct answer is to limit sodium to 2000 mg or less per day. Ascites, which is the abnormal accumulation of fluid in the abdominal cavity, is commonly associated with liver disease. Limiting sodium intake helps manage fluid retention by reducing the fluid accumulation in the abdomen. Choices A, B, and C are incorrect because reducing complex carbohydrates, restricting protein intake, or decreasing caloric intake are not the primary interventions for managing ascites in liver disease.

4. Weight loss therapies that rely on juicing typically provide increased fiber, vitamins, and minerals. As an added incentive, juices contain a lower concentration of sugar than the whole fruit. Are these statements true or false?

• A. Both statements are true
• B. Both statements are false
• C. The first statement is true; the second is false
• D. The first statement is false; the second is true

Correct answer: B

Rationale: The correct answer is both statements are false. The process of juicing often extracts the liquid components of fruits and vegetables, leaving behind the fiber-rich pulp. Therefore, juicing does not typically provide increased fiber. Additionally, juices can contain a higher concentration of sugar than whole fruits because the fiber, which helps to slow down the absorption of sugar, has been removed. This can lead to a spike in blood sugar levels after consumption. The other options are incorrect because they contain at least one false statement.

5. A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?

• A. BUN 8 mg/dL
• B. Hgb 15 g/dL
• C. Creatinine 0.8 mg/dL
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.

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