Nursing Elites

1. Which dietary consideration is most important for the nurse to teach to a client with hypothyroidism?

• A. Increase carbohydrate intake
• B. Increase fluid intake
• C. Avoid shellfish
• D. Increase fiber

Correct answer: D

Rationale: The correct answer is to 'Increase fiber.' In hypothyroidism, clients often experience constipation due to decreased metabolic rate. Increasing fiber in the diet can help alleviate constipation. Choice A, 'Increase carbohydrate intake,' is incorrect as there is no specific need to increase carbohydrate intake in hypothyroidism. Choice B, 'Increase fluid intake,' is not directly related to managing hypothyroidism, although adequate hydration is generally important for overall health. Choice C, 'Avoid shellfish,' is commonly associated with hyperthyroidism due to its iodine content, not hypothyroidism.

2. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

• A. "I had chickenpox when I was 8 years old."?
• B. "I had rheumatic fever when I was 10 years old."?
• C. "I have a strong family history of gastric cancer."?
• D. "I have pain in my hip with any movement."?

Correct answer: B

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

3. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

• A. "I will call your physician to see if we can start some ginger."?
• B. "We don't use home remedies in this clinic."?
• C. "Herbs are not as effective as regular medicines."?
• D. "Just eat some dry crackers instead."?

Correct answer: A

Rationale: The correct response is appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.

4. A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

• A. The client is observed shaving only one side of his face.
• B. The client is unable to distinguish between two tactile stimuli presented simultaneously.
• C. The client is unable to complete a range of vision without turning his head side to side.
• D. The client is unable to carry out cognitive and motor activity at the same time.

Correct answer: A

Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.

5. A client returns to the nursing unit post-thoracotomy with two chest tubes in place connected to a drainage device. The client's spouse asks the nurse about the reason for having two chest tubes. The nurse's response is based on the knowledge that the upper chest tube is placed to:

• A. Remove air from the pleural space
• B. Create access for irrigating the chest cavity
• C. Evacuate secretions from the bronchioles and alveoli
• D. Drain blood and fluid from the pleural space

Correct answer: A

Rationale: The correct answer is 'Remove air from the pleural space.' When a client has two chest tubes in place post-thoracotomy, the upper chest tube is typically positioned to remove air from the pleural space. Air rises, so placing the tube at the top allows for efficient removal of air that has accumulated in the pleural cavity. Choice B, creating access for irrigating the chest cavity, is incorrect as chest tubes are not primarily used for irrigation. Choice C, evacuating secretions from the bronchioles and alveoli, is incorrect as chest tubes are not designed for this purpose. Choice D, draining blood and fluid from the pleural space, is also incorrect as the upper chest tube in this scenario is specifically for removing air, not blood or fluid.

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