Nursing Elites

1. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

2. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?

• A. Apply counter-pressure for back pain
• B. Use deep breathing exercises
• C. Visualize the baby's head
• D. Use massage therapy

Correct answer: A

Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.

3. How should a healthcare professional manage a patient with a suspected stroke?

• A. Monitor for changes in neurological status and administer thrombolytics
• B. Monitor for speech difficulties and administer oxygen
• C. Provide IV fluids and monitor blood pressure
• D. Administer pain relief and monitor for respiratory failure

Correct answer: A

Rationale: Corrected Rationale: When managing a patient with a suspected stroke, it is crucial to monitor for changes in neurological status as this can provide important information about the patient's condition. Administering thrombolytics, if indicated, is a critical intervention in the acute phase of an ischemic stroke to help dissolve blood clots and restore blood flow to the brain. This choice is the correct answer because it addresses the immediate management needs of a patient with a suspected stroke. Choices B, C, and D are incorrect because while monitoring for speech difficulties, administering oxygen, providing IV fluids, monitoring blood pressure, administering pain relief, and monitoring for respiratory failure are important aspects of patient care, they are not the primary interventions for managing a suspected stroke.

4. How should a healthcare professional manage a patient with diarrhea?

• A. Provide oral fluids and monitor stool consistency
• B. Administer antidiarrheal medications and monitor hydration
• C. Monitor for electrolyte imbalances and provide antibiotics
• D. Provide a low-fiber diet and monitor weight

Correct answer: A

Rationale: For a patient with diarrhea, the priority is to manage dehydration by providing oral fluids and monitoring stool consistency. Option B suggesting administering antidiarrheal medications is not recommended as it may prolong the infection by preventing the body from expelling the infectious agent. Option C is incorrect because antibiotics are not routinely indicated for diarrhea unless there is a specific bacterial infection. Option D is not the most appropriate initial intervention for managing diarrhea since a low-fiber diet may not provide adequate nutrition for the patient or help resolve the underlying cause of diarrhea.

5. Which lifestyle modification should be emphasized for a client with hypertension?

• A. Increase sodium intake
• B. Reduce caffeine and alcohol intake
• C. Eat carbohydrate-rich meals
• D. Increase protein intake

Correct answer: B

Rationale: The correct answer is to reduce caffeine and alcohol intake for a client with hypertension. Caffeine and alcohol can increase blood pressure, so reducing their intake can help manage hypertension. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and increased blood pressure. Eating carbohydrate-rich meals (Choice C) is also not ideal as excessive carbohydrates can contribute to weight gain, which can worsen hypertension. Similarly, increasing protein intake (Choice D) is not a primary focus for managing hypertension unless a specific protein deficiency is present.

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