Nursing Elites

1. When assessing a client for risk of hyperphosphatemia, which piece of information is most important for the nurse to obtain?

• A. A history of radiation treatment in the neck region
• B. A history of recent orthopedic surgery
• C. A history of minimal physical activity
• D. A history of the client's food intake

Correct answer: A

Rationale: The correct answer is a history of radiation treatment in the neck region. Previous radiation to the neck may have damaged the parathyroid glands, which are crucial for calcium and phosphorus regulation. This damage can lead to disruptions in phosphorus levels, increasing the risk of hyperphosphatemia. Choices B, C, and D are not as directly related to phosphorus regulation. Orthopedic surgery, minimal physical activity, and food intake are more closely associated with calcium levels rather than phosphorus regulation. Therefore, it is essential for the nurse to focus on obtaining information about a history of radiation treatment in the neck region when assessing the risk of hyperphosphatemia in a client.

2. The nurse is preparing a client for mammography. To prepare the client for a mammogram, the nurse should tell the client:

• A. To omit creams, powders, or deodorants before the exam
• B. To restrict fat intake for 1 week before the test
• C. That mammography replaces the need for self-breast exams
• D. That mammography requires a higher dose of radiation than an x-ray

Correct answer: A

Rationale: The client undergoing a mammogram should be instructed to omit deodorants or powders beforehand because they can interfere with the imaging results. Answer A is correct as it aligns with the preparation needed before a mammogram to ensure accurate results. Answer B is incorrect because there is no requirement for fat intake restrictions before a mammogram. Answer C is incorrect because mammography does not replace the necessity of self-breast exams; both are crucial for maintaining breast health. Answer D is incorrect because a mammogram does not require higher doses of radiation than an x-ray. In fact, mammography uses a low dose of radiation to create images for breast examination.

3. An infant weighs 7 pounds at birth. What is the expected weight by 1 year of age?

• A. 10 pounds
• B. 12 pounds
• C. 18 pounds
• D. 21 pounds

Correct answer: D

Rationale: A birth weight of 7 pounds typically triples by the age of 1 year, resulting in an expected weight of 21 pounds. This significant weight gain is a normal growth pattern for infants as they usually experience rapid growth in the first year of life. Choices A, B, and C are incorrect because they do not account for the usual growth rate of an infant in the first year. Infants commonly triple their birth weight by the age of 1, making 21 pounds the expected weight.

4. Which laboratory test would be the least effective in diagnosing a myocardial infarction?

• A. AST
• B. Troponin
• C. CK-MB
• D. Myoglobin

Correct answer: A

Rationale: AST, choice A, would be the least effective in diagnosing a myocardial infarction as it is not specific for this condition. Troponin, CK-MB, and myoglobin (choices B, C, and D) are more specific markers for myocardial infarction. Troponin is considered the gold standard due to its cardiac specificity. CK-MB is also specific to the heart, and its isoenzyme levels elevate post-heart damage. Myoglobin, although elevated in myocardial infarction, is not as specific as troponin and CK-MB and can also increase in conditions like burns and muscle trauma. Therefore, AST is the least effective choice for diagnosing a myocardial infarction.

5. A client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:

• A. Actual Chronic Low Self-Esteem (related to obesity).
• B. Potential Chronic Low Self-Esteem (related to obesity).
• C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
• D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).

Correct answer: D

Rationale: In this scenario, the client's recent weight loss and subsequent pregnancy could lead to concerns about weight regain and body image. The most appropriate nursing diagnosis is 'Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).' This diagnosis reflects the client's potential emotional response to the fear of losing the progress achieved through weight loss and dealing with changes in body image due to pregnancy. Options A and C imply that low self-esteem is already present, which is not supported by the information given. Option B is not as suitable as the client's self-esteem issues are more related to the fear of weight regain and pregnancy, making option D the best choice.

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