Nursing Elites

1. The nurse is providing discharge teaching to a client with a new diagnosis of diabetes mellitus. Which statement by the client indicates a need for further teaching?

• A. I will need to monitor my blood sugar levels daily.
• B. I will follow a diet low in carbohydrates.
• C. I will rotate the injection sites for my insulin.
• D. I will exercise regularly to help manage my diabetes.

Correct answer: B

Rationale: The correct answer is B. The statement 'I will follow a diet low in carbohydrates' indicates a need for further teaching. In diabetes mellitus, it is essential to follow a balanced diet that includes carbohydrates, proteins, and fats. Carbohydrates are a major source of energy and should be included in moderation to help manage blood sugar levels. Monitoring blood sugar levels daily (A), rotating injection sites for insulin (C), and exercising regularly (D) are all appropriate self-management strategies for individuals with diabetes mellitus.

2. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?

• A. provide the client with 4 ounces of orange juice
• B. call 911 to summon emergency assistance
• C. check the client for lacerations or fractures
• D. assess the client's blood sugar level

Correct answer: C

Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.

3. A client with a history of hypertension is admitted with acute renal failure. Which assessment finding requires immediate intervention?

• A. Blood pressure of 180/100 mm Hg.
• B. Urine output of 50 mL in 4 hours.
• C. Heart rate of 100 beats per minute.
• D. Nausea and vomiting.

Correct answer: B

Rationale: Urine output of 50 mL in 4 hours indicates oliguria, which can be a sign of worsening renal function and requires immediate intervention. In acute renal failure, maintaining adequate urine output is crucial to prevent further kidney damage and manage fluid balance. A high blood pressure reading (Option A) is concerning but may not require immediate intervention in this scenario as it could be due to the history of hypertension. A heart rate of 100 beats per minute (Option C) is slightly elevated but may not be the most critical finding at this moment. Nausea and vomiting (Option D) are important to assess but are not as urgent as addressing oliguria in a client with acute renal failure.

4. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?

• A. Graves' disease.
• B. Cushing's syndrome.
• C. Addison's disease.
• D. Hypothyroidism.

Correct answer: A

Rationale: The correct answer is A, Graves' disease. The symptoms described in the client are classic manifestations of hyperthyroidism, which is commonly caused by Graves' disease, an autoimmune condition affecting the thyroid. Weight loss, racing heart rate, difficulty sleeping, moist skin with fine hair, prominent eyes, lid retraction, and a staring expression are all indicative of hyperthyroidism. Choice B, Cushing's syndrome, is characterized by weight gain, hypertension, and a rounded face due to excess cortisol. Choice C, Addison's disease, presents with symptoms such as weight loss, fatigue, and hyperpigmentation due to adrenal insufficiency. Choice D, hypothyroidism, typically features symptoms opposite to those described in the client, such as weight gain, bradycardia, and dry skin.

5. The healthcare provider is assessing a client with a suspected myocardial infarction. Which finding requires immediate intervention?

• A. Chest pain radiating to the left arm.
• B. Shortness of breath.
• C. Nausea and vomiting.
• D. Diaphoresis.

Correct answer: B

Rationale: Shortness of breath is a critical sign that can indicate heart failure or pulmonary edema, conditions that require immediate intervention in a client with a suspected myocardial infarction. Chest pain radiating to the left arm is a classic symptom of a myocardial infarction but may not necessitate immediate intervention compared to severe shortness of breath. Nausea and vomiting can be present in myocardial infarction but are not as urgent as shortness of breath. Diaphoresis, or sweating, is a common symptom of a myocardial infarction but may not be as immediately concerning as significant shortness of breath.

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