Nursing Elites

1. Salome was fitted a hearing aid. She understood the proper use and wear of this device when she says that the battery should be functional, the device is turned on and adjusted to a:

• A. therapeutic level
• B. comfortable level
• C. prescribed level
• D. audible level

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.

2. What is the most likely demonstration of cardiac cachexia?

• A. Decreased physical activity
• B. Weight loss and tissue wasting
• C. Poor urine output and tissue edema
• D. Cardiac arrhythmia and wet lung sounds

Correct answer: B

Rationale: Cardiac cachexia is a condition characterized by severe weight loss and tissue wasting. This typically occurs in patients suffering from heart failure due to an increased energy expenditure and reduced appetite, which is why choice B is the correct answer. The other choices are incorrect as they do not accurately describe the symptoms of cardiac cachexia. Decreased physical activity (choice A) can be a result of many conditions, not specifically cardiac cachexia. Poor urine output and tissue edema (choice C) are more indicative of kidney problems rather than cardiac cachexia. Finally, cardiac arrhythmia and wet lung sounds (choice D) are symptoms related to other cardiac conditions, not specifically to cardiac cachexia.

3. What dietary factor raises triglyceride levels?

• A. high refined carbohydrate intake
• B. low soluble fiber intake
• C. high iron intake
• D. low fat intake

Correct answer: A

Rationale: The correct answer is A: high refined carbohydrate intake. High intake of refined carbohydrates, such as sugars and white flour, can lead to elevated triglyceride levels, increasing the risk of cardiovascular disease. Choice B, low soluble fiber intake, is incorrect because soluble fiber actually helps lower triglyceride levels. Choice C, high iron intake, is incorrect as iron intake is not directly linked to raising triglyceride levels. Choice D, low fat intake, is also incorrect as not all fats raise triglyceride levels; it depends on the type of fat consumed.

4. A nurse is developing a plan of care for a client who has anorexia nervosa. Which of the following actions should the nurse include in the plan?

• A. Encourage the client to participate in developing a system of rewards.
• B. Arrange for someone to remain with the client for 30 minutes after meals.
• C. Offer the client a selection of beverages at each meal.
• D. Inform the client that a weight gain of 2.3 kg per week is expected.

Correct answer: A

Rationale: Encouraging the client to participate in developing a system of rewards is an essential part of the plan of care for a client with anorexia nervosa. This action can help motivate and engage the client in their treatment plan, promoting a sense of achievement and progress. Choice B, arranging for someone to remain with the client for 30 minutes after meals, may not address the underlying issues related to anorexia nervosa and could potentially disrupt the client's independence. Choice C, offering a selection of beverages at each meal, is not directly related to addressing the client's condition of anorexia nervosa. Choice D, informing the client about an expected weight gain, could increase anxiety and may not be appropriate without considering the client's individual progress and readiness.

5. When taking a blood pressure reading, where should the cuff be positioned?

• A. The cuff should be deflated fully before immediately starting a second reading for the same patient
• B. The cuff should be deflated quickly after being inflated to 180 mmHg
• C. The cuff should be large enough to wrap around the upper arm of the adult patient, positioned 1 cm above the brachial artery
• D. The cuff should be inflated to 30 mmHg above the estimated systolic BP based on palpation of the radial or brachial artery

Correct answer: D

Rationale: When measuring blood pressure, the cuff should be inflated to 30 mmHg above the estimated systolic blood pressure based on palpation of the radial or brachial artery. This ensures an accurate blood pressure measurement. Choices A, B, and C are incorrect. Deflating the cuff fully before starting a second reading (Choice A) does not directly relate to the position of the cuff during a reading. Deflating the cuff quickly after inflating to 180 mmHg (Choice B) is not recommended because it can potentially lead to inaccurate readings. While ensuring the cuff is large enough to wrap around the upper arm positioned 1 cm above the brachial artery is important (Choice C), this alone does not guarantee an accurate blood pressure reading. The correct inflation based on palpation is the key element for accuracy, which is why Choice D is correct.

Similar Questions