Nursing Elites

1. When measuring the leg circumference of a client with bipedal edema, what position is best to ensure accurate measurements?

• A. Dorsal recumbent
• B. Sitting
• C. Standing
• D. Supine

Correct answer: A

Rationale: When measuring the leg circumference of a client with bipedal edema, the best position to ensure accurate and consistent measurements is the dorsal recumbent position. This position allows the legs to be positioned comfortably, and the individual is lying on their back with legs extended, facilitating accurate measurement of the circumference without the influence of gravity. Sitting, standing, and supine positions may not provide optimal conditions for accurate leg circumference measurements, particularly in clients with bipedal edema where positioning and consistency are crucial. Sitting and standing positions may not allow for consistent leg positioning and could introduce errors due to the effects of gravity on the fluid distribution. The supine position, while similar to dorsal recumbent, may not be as comfortable for the client and could still be influenced by gravity when measuring leg circumference.

2. What causes hepatic encephalopathy?

• A. Buildup of ammonia in the body
• B. Buildup of urea in the body
• C. Fatty infiltration of the liver
• D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

3. The nurse is preparing a teaching care plan for the client diagnosed with nephritic syndrome. Which intervention should the nurse include?

• A. Discontinue the use of steroid therapy immediately if symptoms develop.
• B. Take diuretics as needed to treat the dependent edema in ankles.
• C. Increase the intake of dietary sodium every day to decrease fluid retention.
• D. Report any decrease in daily weight during treatment to the healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Reporting a decrease in daily weight is crucial when managing nephritic syndrome as it can indicate worsening of the condition or dehydration. It is essential to monitor weight changes closely to assess the effectiveness of treatment and the client's fluid status. Choice A is incorrect because discontinuing steroid therapy abruptly can lead to complications; gradual tapering is usually recommended. Choice B is incorrect as diuretics should be taken as prescribed by the healthcare provider to manage fluid retention. Choice C is also incorrect because increasing dietary sodium can exacerbate fluid retention, which is counterproductive in nephritic syndrome.

4. A patient with Crohn’s disease is experiencing diarrhea. Which dietary recommendation is appropriate?

• A. High-fiber diet
• B. Low-residue diet
• C. High-fat diet
• D. High-protein diet

Correct answer: B

Rationale: A low-residue diet is the appropriate dietary recommendation for a patient with Crohn’s disease experiencing diarrhea. This diet helps reduce bowel movements and manage diarrhea by limiting the intake of foods that are harder to digest. High-fiber diets (Choice A) may worsen diarrhea due to increased bulk in the stool. High-fat diets (Choice C) can be harder to digest and may exacerbate symptoms. High-protein diets (Choice D) are not specifically recommended for managing diarrhea in Crohn’s disease.

5. The nurse enters a client’s room and the client is demanding release from the hospital. The nurse reviews the client’s record and notes that the client was admitted 2 days ago for treatment of an anxiety disorder, and the admission was voluntary. Which intervention should the nurse initiate first?

• A. Telephone the client’s family and have them persuade the client to stay
• B. Have the client read and sign all the appropriate self-discharge papers
• C. Explain to the client that he cannot leave because he asked for treatment
• D. Notify the client’s healthcare provider of the client’s stated intent to leave the hospital

Correct answer: D

Rationale: The correct intervention for the nurse to initiate first is to notify the client’s healthcare provider of the client’s intention to leave the hospital. This is important to ensure that the client’s care and safety are appropriately managed. Option A is incorrect as involving the family without proper assessment or intervention could violate the client's autonomy. Option B is incorrect because it does not involve the healthcare provider in the decision-making process. Option C is incorrect as it does not address the client's rights to make decisions about their own care.

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