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 teaching a client with heart failure about dietary restrictions. What food should be limited?

• A. Bananas
• B. Leafy green vegetables
• C. Potatoes
• D. Whole grains

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, which should be limited in clients with heart failure to prevent electrolyte imbalances. While leafy green vegetables and whole grains are generally healthy options, they are not typically restricted in heart failure patients. Potatoes, although they contain potassium, are not as high in potassium as bananas and are not usually restricted as strictly.

3. During a home visit to an elderly client with mild dementia, the client's daughter reports that she has one major problem with her mother. She says, 'She sleeps most of the day and is up most of the night. I can't get a decent night's sleep anymore.' Which suggestions should the nurse make to the daughter?

• A. Ask the client's physician for a strong sleep medicine
• B. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime
• C. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day
• D. Promote relaxation before bedtime with a warm bath or relaxing music

Correct answer: B

Rationale: The correct answer is to establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. By creating a structured daily schedule, the client's natural sleep-wake cycle can be regulated, helping to address the issue of daytime sleeping and nighttime wakefulness. Option A, asking for a strong sleep medicine, may not address the underlying cause and can have potential side effects in the elderly. Option C, engaging in exercises when drowsy, may not be suitable for someone with dementia and could disrupt sleep patterns further. Option D, promoting relaxation before bedtime, is helpful but may not be sufficient to address the client's significant sleep issue.

4. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

5. A nurse is teaching a client with diabetes about insulin administration. What is the most important point to emphasize?

• A. Check blood sugar once in the morning
• B. Administer insulin before meals as prescribed
• C. Administer insulin only when feeling unwell
• D. Monitor blood sugar only in the evening

Correct answer: B

Rationale: The most important point to emphasize when teaching a client with diabetes about insulin administration is to administer insulin before meals as prescribed. This is crucial for maintaining proper blood sugar control throughout the day. Choice A is incorrect because blood sugar levels need to be monitored multiple times a day, not just once in the morning. Choice C is incorrect because insulin should be administered according to the prescribed schedule, not only when feeling unwell. Choice D is incorrect because blood sugar monitoring should be done at various times during the day, not just in the evening.

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