Nursing Elites

1. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

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. Diego is undergoing blood transfusion of the first unit. The earliest signs of transfusion reactions are:

• A. Oliguria and jaundice
• B. Urticaria and wheezing
• C. Headache, chills, & fever
• D. Hypertension and flushing

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. The nurse is caring for an infant whose parent reports the infant takes a bottle to go to sleep. What should the nurse instruct to prevent baby bottle tooth decay?

• A. Water
• B. Milk
• C. Iron-fortified formula
• D. Unsweetened fruit juice

Correct answer: A

Rationale: The correct answer is A, Water. Water is recommended to prevent baby bottle tooth decay caused by sugary substances present in milk, formula, or fruit juice. Water does not contain sugars that can contribute to tooth decay, unlike the other options. Milk, formula, and unsweetened fruit juice can all lead to tooth decay if the baby falls asleep with them in their mouth, as the sugars can linger on the teeth and cause decay over time. Iron-fortified formula, although beneficial for the infant's nutrition, still contains sugars that can be harmful to the teeth.

4. People with only one arm or hand may benefit from using a ____ when eating?

• A. dish with suction cups
• B. rocker knife
• C. utensil holder
• D. flexible straw

Correct answer: B

Rationale: A rocker knife is specifically designed for individuals with limited use of one hand or arm, allowing them to cut food easily. This makes it a suitable option for people with only one arm or hand. Choice A, a dish with suction cups, may not directly aid in cutting food with one hand. Choice C, an utensil holder, is not typically used for cutting food. Choice D, a flexible straw, is more related to drinking liquids and not specifically designed to assist in cutting food one-handed.

5. A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?

• A. BUN 8 mg/dL
• B. Hgb 15 g/dL
• C. Creatinine 0.8 mg/dL
• D. Sodium 140 mEq/L

Correct answer: A

Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.

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