Nursing Elites

1. The healthcare professional is developing a care plan for a client with depression. What should be included in the plan?

• A. Regular physical activity
• B. Scheduled sleep patterns
• C. Social interaction with family and friends
• D. All of the above

Correct answer: D

Rationale: A comprehensive care plan for a client with depression should include multiple components to address various aspects of health. Regular physical activity can help improve mood and overall well-being. Scheduled sleep patterns are essential as sleep disturbances are common in depression and can worsen symptoms. Social interaction with family and friends provides emotional support and reduces feelings of isolation. Therefore, including all these aspects in the care plan can help support the client's recovery. Choice D, 'All of the above,' is the correct answer because all the options are important components of a holistic care plan for depression. Choices A, B, and C are incorrect because each of these elements plays a crucial role in managing depression.

2. The client with hypertension is being taught about lifestyle modifications. What topic is most important?

• A. Stress management
• B. Salt intake reduction
• C. Regular physical activity
• D. Weight loss

Correct answer: B

Rationale: Reducing salt intake is crucial for managing hypertension. Excessive salt consumption can lead to fluid retention, increasing blood pressure. While stress management, regular physical activity, and weight loss are beneficial for overall health, reducing salt intake is the most important lifestyle modification for controlling hypertension. Stress management may help reduce overall stress levels but does not directly impact blood pressure as salt intake does. Regular physical activity and weight loss can also benefit blood pressure control, but the immediate impact of reducing salt intake is more significant.

3. The nurse is caring for a client with cirrhosis of the liver. Which clinical finding is most concerning?

• A. Jaundice.
• B. Ascites.
• C. Spider angiomas.
• D. Asterixis.

Correct answer: D

Rationale: The correct answer is D, Asterixis. Asterixis, also known as liver flap, is a sign of hepatic encephalopathy, a severe complication of liver disease that necessitates immediate attention. While jaundice (choice A), ascites (choice B), and spider angiomas (choice C) are common clinical findings in cirrhosis, asterixis is the most concerning due to its association with hepatic encephalopathy, which can lead to altered mental status and even coma. Jaundice, ascites, and spider angiomas are also important signs in cirrhosis, but asterixis indicates a more critical condition requiring urgent intervention.

4. When counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse do?

• A. Recheck the radial pulse in thirty minutes
• B. Palpate the radial pulse for thirty seconds and double the rate
• C. Count the apical pulse rate for sixty seconds
• D. Compare the radial pulse rate bilaterally and record the higher rate

Correct answer: C

Rationale: The correct answer is to count the apical pulse rate for sixty seconds. The apical pulse is more accurate, especially when peripheral pulses are weak or irregular. Counting the apical pulse for a full minute provides a more precise heart rate measurement. Option A is incorrect because waiting for thirty minutes is unnecessary and could delay potential interventions. Option B is incorrect because doubling the radial pulse rate may not provide an accurate representation of the heart rate. Option D is incorrect because comparing radial pulses bilaterally does not give the most accurate heart rate measurement; the apical pulse is preferred in this situation.

5. Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?

• A. Application of topical antibacterial cream
• B. Use of careful hand washing technique
• C. Administration of plasma expanders
• D. Limiting visitors to the burned client

Correct answer: B

Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.

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