Nursing Elites

1. The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, 'Imbalanced nutrition: More than body requirements'?

• A. Hypertension.
• B. Diabetes mellitus.
• C. Inadequate lifestyle changes in diet and exercise.
• D. Increased risk of chronic illnesses.

Correct answer: C

Rationale: The correct answer is C: 'Inadequate lifestyle changes in diet and exercise.' When a client's weight exceeds the standardized height-weight scale significantly, it indicates an imbalance between nutrition intake and energy expenditure, leading to 'Imbalanced nutrition: More than body requirements.' Inadequate lifestyle changes in diet and exercise directly contribute to this imbalance by promoting excessive caloric intake and reduced physical activity. Choices A, B, and D are incorrect because while conditions like hypertension, diabetes mellitus, and increased risk of chronic illnesses may be consequences of imbalanced nutrition, they are not the direct related factor that should be included in formulating the nursing problem.

2. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?

• A. Supine with the foot of the bed raised.
• B. On the left side with legs elevated.
• C. On the right side with legs elevated.
• D. Prone with head elevated.

Correct answer: A

Rationale: In the scenario of a primipara with a breech presentation and a prolapsed umbilical cord, the nurse should place the client in the supine position with the foot of the bed raised (Trendelenburg position). This position helps alleviate gravitational pressure by the fetus on the cord, preventing compression and reducing the risk of cord prolapse complications. Placing the client on the left or right side with legs elevated or in a prone position with the head elevated would not be appropriate in this situation, as they do not effectively relieve the pressure on the umbilical cord.

3. During a prenatal class for expectant mothers, what topic should be included to ensure the health of both the mother and the baby?

• A. importance of taking prenatal vitamins
• B. how to handle common discomforts of pregnancy
• C. preparing for labor and delivery
• D. breastfeeding techniques

Correct answer: A

Rationale: The correct answer is the importance of taking prenatal vitamins. Prenatal vitamins are crucial for the health of both the mother and the baby as they provide essential nutrients required for fetal development. While handling common discomforts of pregnancy (choice B) is important for maternal well-being, it does not directly impact the health of the baby. Preparing for labor and delivery (choice C) focuses more on the delivery process rather than the overall health of the mother and baby during pregnancy. Breastfeeding techniques (choice D) are relevant postpartum, not during the prenatal period, and do not directly impact the health of the baby during pregnancy.

4. Which bioterrorism agent is at high risk for use as a potential biological weapon that is readily transmitted by several portals of entry?

• A. anthrax
• B. smallpox
• C. botulism
• D. tularemia

Correct answer: A

Rationale: Anthrax is the correct answer. Anthrax spores can be transmitted through inhalation, ingestion, or skin contact, making it a high-risk agent for bioterrorism. Smallpox, botulism, and tularemia are also potential bioterrorism agents, but they do not have the same versatility in terms of multiple portals of entry, unlike anthrax.

5. A client with a history of coronary artery disease is admitted with chest pain. Which finding requires immediate intervention?

• A. Heart rate of 90 beats per minute.
• B. Blood pressure of 130/80 mm Hg.
• C. Respiratory rate of 20 breaths per minute.
• D. Chest pain radiating to the left arm.

Correct answer: D

Rationale: The correct answer is D. Chest pain radiating to the left arm can be a sign of myocardial infarction (heart attack) and requires immediate intervention. This symptom is known as a classic presentation of a heart attack and warrants urgent medical attention to prevent further cardiac damage. Choices A, B, and C are not directly indicative of an acute cardiac event and may not require immediate intervention in this scenario. While heart rate, blood pressure, and respiratory rate are important vital signs to monitor, they do not specifically indicate the urgency associated with chest pain radiating to the left arm in a patient with a history of coronary artery disease.

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