Nursing Elites

1. Which client is at greatest risk for developing delirium?

• A. An adult client who cannot sleep due to pain.
• B. An older client who attempted suicide 1 month ago.
• C. A young adult taking antipsychotic medications twice daily.
• D. A middle-aged woman using supplemental oxygen.

Correct answer: B

Rationale: The correct answer is B. Older adults who have attempted suicide are at higher risk for developing delirium, especially in the context of underlying mental health conditions. Choice A is incorrect as sleep disturbances due to pain may lead to discomfort but not necessarily delirium. Choice C is incorrect as taking antipsychotic medications, if managed well, does not inherently increase the risk of delirium. Choice D is incorrect as using supplemental oxygen alone does not significantly increase the risk of developing delirium.

2. The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

• A. Weight-bearing exercise
• B. Aerobic exercise
• C. Low-impact exercises such as swimming
• D. Stretching and flexibility exercises

Correct answer: A

Rationale: The correct answer is A: Weight-bearing exercise. Weight-bearing exercise helps build and maintain bone density, which is critical in preventing osteoporosis. Activities like aerobic exercises, stretching, and low-impact exercises such as swimming are beneficial for overall fitness but do not directly contribute to improving bone strength, making them less effective in preventing osteoporosis.

3. A client with a prescription for DNR begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?

• A. Inform the healthcare provider
• B. Determine the client's need for pain medication
• C. Begin comfort measures
• D. Ensure all life-saving equipment is removed

Correct answer: B

Rationale: The correct priority action for the nurse to implement in this scenario is to determine the client's need for pain medication. Ensuring that the client is comfortable and free from pain is crucial in end-of-life care, especially for a client with a Do Not Resuscitate (DNR) order. This action prioritizes the client's comfort and dignity in their final moments. While informing the healthcare provider and beginning comfort measures are important aspects of care, pain management takes precedence as the immediate priority. Removing life-saving equipment is not appropriate at this stage as it goes against the client's wishes stated in the DNR order.

4. A nurse is planning discharge teaching for a client with congestive heart failure (CHF). Which dietary instruction should the nurse provide?

• A. Limit sodium intake to reduce fluid retention
• B. Consume high-protein foods to strengthen the heart
• C. Increase potassium intake to manage blood pressure
• D. Increase fluid intake to promote hydration

Correct answer: A

Rationale: The correct answer is A: Limit sodium intake to reduce fluid retention. Limiting sodium intake is crucial for managing congestive heart failure (CHF) as it helps reduce fluid retention. Excess fluid retention can worsen CHF by increasing the workload on the heart. Choice B is incorrect because while protein is essential for overall health, it is not directly related to managing CHF. Choice C is incorrect because potassium, although important, is not the primary focus in managing CHF. Choice D is incorrect because increasing fluid intake can exacerbate fluid retention in CHF patients.

5. A client with multiple sclerosis is admitted with an acute exacerbation. What is the nurse's priority action?

• A. Monitor the client’s vital signs every hour.
• B. Assess for changes in the client’s muscle strength.
• C. Administer prescribed corticosteroids to reduce inflammation.
• D. Educate the client on managing fatigue and preventing relapses.

Correct answer: C

Rationale: The correct answer is C. Administering prescribed corticosteroids to reduce inflammation is the priority action when a client with multiple sclerosis is admitted with an acute exacerbation. Corticosteroids help manage symptoms during exacerbations and reduce inflammation. Monitoring vital signs and assessing muscle strength are important aspects of care but not the priority during an acute exacerbation. Educating the client on managing fatigue and preventing relapses is essential but can be addressed after the acute exacerbation has been managed.

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