Nursing Elites

1. The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?

• A. The child looks at the floor when answering the nurse's questions
• B. The mother's version of the injury is different from the child's version
• C. The child has several abrasions on the chest and legs
• D. The mother refuses to answer questions about family history

Correct answer: B

Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.

2. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

• A. Increase potassium-rich foods in the diet
• B. Avoid foods high in sodium
• C. Monitor fluid intake and adjust as needed
• D. Take the medication in the morning

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

3. The client with hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake
• B. Engage in regular physical activity
• C. Consume a diet high in saturated fats
• D. Limit fluid intake

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for managing hypertension as it helps lower blood pressure. Regular exercise can improve heart health, increase circulation, and contribute to overall well-being, all of which are beneficial for individuals with hypertension. Choice A, increasing sodium intake, is incorrect as reducing sodium is recommended for hypertension to help lower blood pressure. Choice C, consuming a diet high in saturated fats, is incorrect as a diet high in saturated fats can negatively impact blood pressure and cardiovascular health. Choice D, limiting fluid intake, is incorrect as maintaining adequate hydration is important for overall health and not directly related to hypertension management.

4. A client with a history of atrial fibrillation is prescribed warfarin. Which lab value should the nurse monitor to assess the effectiveness of this medication?

• A. Hemoglobin
• B. White blood cell count
• C. Platelet count
• D. INR

Correct answer: D

Rationale: The correct answer is D, INR (International Normalized Ratio). The INR is used to monitor the effectiveness of warfarin therapy. Warfarin is an anticoagulant medication commonly prescribed for conditions like atrial fibrillation. Monitoring the INR helps healthcare providers ensure that the blood is clotting within a therapeutic range. Hemoglobin (Choice A), white blood cell count (Choice B), and platelet count (Choice C) are not directly related to monitoring the effectiveness of warfarin therapy in this context.

5. A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?

• A. Restrict fluid intake
• B. Provide a high-sodium diet
• C. Encourage vigorous exercise
• D. Administer bronchodilators as prescribed

Correct answer: A

Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.

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