Nursing Elites

1. Maria’s statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” is an example of:

• A. Delusion of grandeur
• B. Visual Hallucination
• C. Religious delusion
• D. Auditory Hallcucination

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

2. A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?

• A. A client who is postoperative following a laminectomy and is receiving IV PCA
• B. A client who has dysphagia and does not recognize his family
• C. A client who has COPD and is going home with oxygen
• D. A client who has colon cancer and will undergo a hemicolectomy

Correct answer: D

Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.

3. During blood administration, what is essential for the nurse to do in order to carefully monitor for adverse reactions?

• A. Stay with the client for the first 15 minutes of blood administration
• B. Stay with the client for the entire period of blood administration
• C. Run the infusion at a faster rate during the first 15 minutes
• D. Inform the client to notify the staff immediately for any adverse reaction

Correct answer: A

Rationale: In the context of blood administration, it's crucial for the nurse to stay with the client for the first 15 minutes. This is because most adverse reactions are likely to occur within this initial period. Monitoring the client closely during this time allows for immediate detection and response to any potential reactions. Choice B, staying with the client for the entire period of blood administration, is not typically feasible or necessary, although regular checks should be conducted. Running the infusion at a faster rate during the first 15 minutes (Choice C) is incorrect as this can actually increase the risk of adverse reactions. Informing the client to notify the staff immediately for any adverse reaction (Choice D) is an important practice, but it is not the most direct way for the nurse to monitor for adverse reactions.

4. What should be recommended to help prevent early childhood caries (ECC) in infants?

• A. Avoid giving the infant nighttime bottles
• B. Have the infant drink pasteurized skim milk
• C. Feed the infant iron-rich foods
• D. Give the infant fruit juice to drink

Correct answer: A

Rationale: The correct answer is 'A: Avoid giving the infant nighttime bottles' because prolonged exposure to sugars in milk during the night can lead to caries. Options 'B: Have the infant drink pasteurized skim milk' and 'D: Give the infant fruit juice to drink' are not recommended as they contain sugars that can cause cavities, especially in infants. Option 'C: Feed the infant iron-rich foods' is incorrect because while a balanced diet is important, iron-rich foods do not directly prevent caries development.

5. A client who has dumping syndrome following a hemi-colectomy should avoid which of the following foods when receiving nutritional teaching from a nurse?

• A. Rice
• B. Poached eggs
• C. Fresh apples
• D. White bread

Correct answer: C

Rationale: Fresh apples should be avoided by a client with dumping syndrome following a hemi-colectomy because they are high in fiber and can exacerbate gastrointestinal symptoms such as diarrhea and bloating. Rice and poached eggs are good options as they are easily digestible and less likely to trigger dumping syndrome symptoms. White bread is also preferable over whole grain bread due to its lower fiber content, making it a better choice for individuals with dumping syndrome.

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