Nursing Elites

1. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

2. In order to establish a therapeutic relationship with the client, the nurse must first have:

• A. Self awareness C. Self acceptance
• B. Self understanding D. Self motivation
• C.
• D.

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

3. When conducting assessments for malnutrition, which risk factors should the nurse consider? (SATA)

• A. Dental problems
• B. Depression
• C. Ability to read and write
• D. All of the above

Correct answer: D

Rationale: When assessing for malnutrition, nurses should consider multiple risk factors. Dental problems and depression can impact a person's ability to eat and maintain proper nutrition. The ability to read and write may not directly relate to malnutrition risk. The correct answer is 'All of the above' because dental problems and depression are indeed risk factors, along with other factors like the inability to prepare meals and the loss of a spouse.

4. Which mental health disorder can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity?

• A. Bulimia
• B. Anorexia nervosa
• C. Depression
• D. Schizophrenia

Correct answer: A

Rationale: The correct answer is A: Bulimia. Bulimia involves repeated episodes of binge eating followed by purging, which can lead to the erosion of lingual enamel, enlarged parotid glands, palatal bruising, and dentinal hypersensitivity. This behavior exposes the teeth to stomach acid during purging, causing damage to the enamel. Choices B, C, and D are incorrect because these conditions are not typically associated with the specific oral health issues mentioned in the question.

5. You will do nasopharyngeal suctioning on Mr. Abad. Your guide for the length of insertion of the tubing for an adult would be:

• A. tip of the nose to the base of the neck
• B. the distance from the tip of the nose to the middle of the neck
• C. the distance from the tip of the nose to the tip of the ear lobe
• D. eight to ten inches

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

Similar Questions