Nursing Elites

1. What are key signs of fluid overload?

• A. Edema
• B. Hypertension
• C. Shortness of breath
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.

2. A nurse is reinforcing discharge teaching with a client who has dependent personality disorder. Which of the following instructions should the nurse include in the discharge teaching?

• A. Limit social interactions
• B. Demonstrate assertiveness
• C. Follow a rigid schedule
• D. Perform deep breathing exercises

Correct answer: B

Rationale: The correct answer is B: 'Demonstrate assertiveness.' For clients with dependent personality disorder, assertiveness training is crucial as it helps them become more independent and develop the skills to express their own needs and preferences effectively. Choice A ('Limit social interactions') is incorrect because promoting healthy social interactions is important for individuals with this disorder to build confidence and reduce dependency. Choice C ('Follow a rigid schedule') is incorrect as overly rigid schedules may exacerbate feelings of helplessness and dependence. Choice D ('Perform deep breathing exercises') is not directly related to addressing the core issues of dependent personality disorder, which primarily involve developing self-reliance and assertiveness.

3. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?

• A. Maintain the client's bed in the lowest position
• B. Use a bed exit alarm system
• C. Assist the client with ambulation every hour
• D. Raise all 4 side rails for safety

Correct answer: B

Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.

4. A nurse is reinforcing discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

• A. I will avoid feeding my baby for 12 hours
• B. I will apply diaper cream during each diaper change
• C. I will give my baby water between feedings
• D. I will apply warm compresses for my baby's comfort

Correct answer: B

Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.

5. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?

• A. Hyperactive reflexes.
• B. Strong, bounding pulse.
• C. Decreased bowel sounds.
• D. Increased deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.

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