Nursing Elites

1. What is the most important intervention when managing a client with delirium?

• A. Administer a sedative to reduce agitation
• B. Identify any reversible causes of delirium
• C. Increase environmental stimulation
• D. Limit noise and provide a calm environment

Correct answer: B

Rationale: The correct answer is B: 'Identify any reversible causes of delirium.' When managing a client with delirium, it is crucial to first identify and address any reversible factors contributing to the delirium. Administering sedatives (Choice A) may worsen delirium and is not the primary intervention. Increasing environmental stimulation (Choice C) can exacerbate symptoms. Limiting noise and providing a calm environment (Choice D) are beneficial but not as crucial as identifying reversible causes.

2. How do you assess for dehydration in a pediatric patient?

• A. Check for dry mouth and decreased urine output
• B. Monitor skin turgor and capillary refill
• C. Assess for lethargy and irritability
• D. Monitor blood pressure and heart rate

Correct answer: A

Rationale: Correct! When assessing for dehydration in a pediatric patient, checking for dry mouth and decreased urine output are crucial indicators. Dry mouth indicates reduced fluid intake or dehydration, while decreased urine output suggests decreased renal perfusion secondary to dehydration. Skin turgor and capillary refill are more indicative of perfusion status rather than dehydration specifically. Lethargy and irritability can be present in dehydrated patients but are more general signs of illness. Monitoring blood pressure and heart rate are important in assessing dehydration severity but are not the initial signs used for assessment.

3. A client diagnosed with gout is receiving dietary instruction from a nurse. What dietary advice should be provided?

• A. Limit intake of fresh fruits and uncooked vegetables
• B. Limit intake of red meat and shellfish
• C. Limit intake of dairy products
• D. Increase intake of leafy greens

Correct answer: B

Rationale: The correct answer is to limit the intake of red meat and shellfish. These foods are high in purines, which can increase uric acid levels and trigger gout flare-ups. Fresh fruits, uncooked vegetables, dairy products, and leafy greens are generally not associated with exacerbating gout symptoms and do not need to be significantly restricted in the diet of someone with gout.

4. What is the first step in assessing a patient with suspected stroke?

• A. Check for facial droop
• B. Assess speech clarity
• C. Perform a neurological assessment
• D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

5. A client with coronary artery disease (CAD) is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your intake of red meat
• B. Increase physical activity to 150 minutes per week
• C. Avoid foods high in fiber
• D. Increase sodium intake to 2,300 mg per day

Correct answer: B

Rationale: The correct answer is B: 'Increase physical activity to 150 minutes per week.' Increasing physical activity is essential for clients with CAD as it helps reduce the risk of cardiovascular events. Choice A is incorrect as red meat is high in saturated fats, which can be detrimental for CAD. Choice C is incorrect as foods high in fiber, such as fruits, vegetables, and whole grains, are beneficial for heart health. Choice D is incorrect as increasing sodium intake can lead to hypertension and worsen CAD.

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