Nursing Elites

1. What laboratory value would be considered a high-risk measure for coronary heart disease assessment?

• A. triglycerides > 150 mg/dL
• B. BMI > 31
• C. LDL cholesterol < 128 mg/dL
• D. blood pressure of 128/82 mmHg

Correct answer: B

Rationale: The correct answer is B: BMI > 31. A BMI over 31 is considered a high-risk factor for coronary heart disease as it indicates obesity, which is strongly linked to cardiovascular issues. Triglycerides > 150 mg/dL (choice A) can contribute to heart disease risk but are not as specific as BMI in assessing overall risk. LDL cholesterol < 128 mg/dL (choice C) is actually a desirable level, indicating lower risk. A blood pressure of 128/82 mmHg (choice D) is within normal range and not a high-risk measure specifically for coronary heart disease.

2. While the client has a pulse oximeter on his fingertip, you notice that sunlight is shining on the area where the oximeter is. Your action will be to:

• A. Set and turn on the alarm of the oximeter
• B. Do nothing since there is no identified problem
• C. Cover the fingertip sensor with a towel or bedsheet
• D. Change the location of the sensor every four hours

Correct answer: B

Rationale: In this scenario, the correct action is to do nothing since there is no identified problem with the sunlight shining on the area where the oximeter is placed. The functionality of the oximeter is not affected by sunlight, so covering it or changing its location unnecessarily could disrupt the monitoring process. Setting the alarm or changing the sensor location every four hours is not indicated in this situation and may lead to unnecessary interventions. It's essential to assess the situation carefully and intervene only when necessary, ensuring that care provided is appropriate and effective.

3. A nurse is providing anticipatory guidance to a client who has Phenylketonuria (PKU) and is planning a pregnancy. Which of the following information should the nurse include in the discussion?

• A. Diet sodas should not be consumed more than two or three times a week.
• B. Serum bilirubin should be monitored once or twice a month during pregnancy.
• C. Breastfeeding will not prevent your baby from developing PKU.
• D. A low-protein diet should be followed for three months before conception.

Correct answer: D

Rationale: A low-protein diet should be followed for three months before conception in individuals with PKU who are planning a pregnancy. This diet helps manage PKU by reducing phenylalanine levels, which is crucial for maternal and fetal health. Choices A, B, and C are incorrect. Choice A is not directly related to managing PKU, choice B focuses on a different aspect of care during pregnancy, and choice C is inaccurate as breastfeeding will not prevent a baby from developing PKU.

4. A client newly diagnosed with hypertension is receiving teaching about the Mediterranean diet from a nurse. Which of the following statements by the client indicates a need for further teaching?

• A. I will limit my intake of red meat to twice weekly.
• B. I can have dairy in moderate portions daily.
• C. I can have fish two times a week.
• D. I can drink wine in moderation.

Correct answer: D

Rationale: The correct answer is D. Patients with hypertension should be advised to limit alcohol consumption, including wine, to help manage their blood pressure. Choices A, B, and C are all consistent with the Mediterranean diet and are appropriate for a client with hypertension. Reducing red meat intake, consuming dairy in moderate portions, and having fish regularly align with the principles of this heart-healthy eating pattern.

5. Ms. Maria Salvacion says that she is the incarnation of the holy Virgin Mary. She said that she is the child of the covenant that would save this world from the evil forces of Satan. One morning, while caring for her, she stood in front of you and said “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” The best response by the Nurse is:

• A. Tell me more about being the Virgin Mary
• B. So, You are the Virgin Mary?
• C. Excuse me but, you are not anymore a Virgin so you cannot be the Blessed Virgin Mary.
• D. You are Maria Salvacion

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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