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. To prevent baby bottle tooth decay, what should the nurse instruct?

• A. Water
• B. Milk
• C. Iron-fortified formula
• D. Unsweetened fruit juice

Correct answer: A

Rationale: The correct answer is A: Water. Water is the best choice to prevent baby bottle tooth decay as it does not cause tooth decay and is a good option for bedtime bottles. Milk (choice B) and iron-fortified formula (choice C) contain sugars that can contribute to tooth decay. Unsweetened fruit juice (choice D) also contains natural sugars that can be harmful to the baby's teeth.

3. You are teaching your clients the difference between Type I (IDDM) and Type II (NDDM) diabetes. Which of the following statements is true?

• A. Both types of diabetes mellitus clients are prone to developing ketosis.
• B. Type II (NIDDM) is more common and preventable compared to Type I (IDDM) diabetes, which is genetic.
• C. Type I (IIDM) is characterized by fasting hyperglycemia.
• D. Type II (NIDDM) is characterized by abnormal immune response.

Correct answer: D

Rationale: The correct answer is D. Type II diabetes (NIDDM) is characterized by insulin resistance and a relative lack of insulin. It is not primarily characterized by an abnormal immune response. Option A is incorrect because only Type I diabetes clients are prone to developing ketosis due to a lack of insulin. Option B is incorrect because while Type II diabetes is more common and often preventable through lifestyle changes, it is not solely genetic. Option C is incorrect because Type I diabetes, not Type II, is characterized by fasting hyperglycemia due to an absolute lack of insulin production.

4. Intrinsic factor from the stomach is needed for the absorption of which vitamin?

• A. vitamin B12
• B. folate
• C. niacin
• D. vitamin B6

Correct answer: A

Rationale: The correct answer is A: vitamin B12. Intrinsic factor is a glycoprotein produced by the stomach that is necessary for the absorption of vitamin B12 in the small intestine. Vitamin B12 binds to intrinsic factor in the stomach, forming a complex that is then absorbed in the ileum. This absorption process is crucial for preventing vitamin B12 deficiency. Choices B, C, and D are incorrect because they do not require intrinsic factor for absorption. Folate is absorbed in the small intestine through a different mechanism, niacin can be absorbed in the small intestine without the need for intrinsic factor, and vitamin B6 does not rely on intrinsic factor for absorption.

5. Being in contact with reality and the environment is a function of the:

• A. conscience
• B. ego
• C. id
• D. super ego

Correct answer: B

Rationale: Being in contact with reality and the environment is a function of the ego. The ego is responsible for mediating between the id's basic desires, the superego's idealistic standards, and the real world. The conscience (not listed as a choice) is related to feelings of guilt or moral responsibility. The id represents primal instincts, and the superego represents the internalized ideals and moral standards.

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