Nursing Elites

1. Which of the following findings indicates a need for immediate attention in a client diagnosed with delirium?

• A. Confusion and disorientation that resolve with rest
• B. A blood pressure reading of 110/70
• C. Irritability and agitation that worsen throughout the day
• D. Mild confusion during the evening hours

Correct answer: C

Rationale: The correct answer is C: Irritability and agitation that worsen throughout the day. These symptoms are concerning in a client diagnosed with delirium as they may indicate an exacerbation of the condition or an underlying cause that requires immediate attention. Option A describes symptoms that resolve with rest, which may not be as urgent. Option B provides a normal blood pressure reading, which is not typically associated with immediate attention in delirium cases. Option D describes mild confusion during specific hours, which may not be as critical as worsening symptoms throughout the day.

2. What are the key differences between viral and bacterial infections?

• A. Viral infections typically last longer than bacterial infections.
• B. Bacterial infections typically cause high fever.
• C. Both bacterial and viral infections cause rashes.
• D. Viral infections cause sudden onset of symptoms.

Correct answer: A

Rationale: The correct answer is A. Viral infections typically last longer than bacterial infections. This is because viral infections often require the body's immune system to fight off the virus, leading to a longer duration of illness. Bacterial infections, on the other hand, often cause a rapid onset of symptoms due to the toxins produced by bacteria. Choice B is incorrect because not all bacterial infections cause high fever. Choice C is incorrect because rashes can be caused by both bacterial and viral infections, but not always. Choice D is incorrect because while some viral infections may cause a sudden onset of symptoms, it is not a key distinguishing factor between viral and bacterial infections.

3. How should a healthcare professional assess and manage a patient with dehydration?

• A. Assess skin turgor and monitor intake/output
• B. Encourage oral fluids only
• C. Administer IV fluids immediately
• D. Check for electrolyte imbalance and administer fluids

Correct answer: A

Rationale: The correct way to assess and manage a patient with dehydration is to assess skin turgor and monitor intake/output. Skin turgor assessment helps in evaluating the degree of dehydration, while monitoring intake/output aids in maintaining fluid balance. Encouraging oral fluids only (Choice B) may not be sufficient for moderate to severe dehydration as patients may need intravenous fluids (IV) to rapidly rehydrate. Administering IV fluids immediately (Choice C) is not always the first step unless the patient is severely dehydrated. Checking for electrolyte imbalance and administering fluids (Choice D) is important but comes after assessing skin turgor and intake/output in the management of dehydration.

4. Which lifestyle change should be emphasized for a client with hypertension?

• A. Increase sodium intake to prevent fluid retention
• B. Reduce sodium and caffeine intake
• C. Increase protein intake to promote muscle strength
• D. Increase intake of high-fat foods

Correct answer: B

Rationale: The correct answer is B: 'Reduce sodium and caffeine intake.' Clients with hypertension benefit from reducing sodium intake as it can help lower blood pressure levels. Caffeine also has a vasoconstrictive effect, which can increase blood pressure. Choices A, C, and D are incorrect. Increasing sodium intake would exacerbate hypertension due to fluid retention. While protein intake is important for overall health, it is not a primary focus in managing hypertension. Increasing intake of high-fat foods can lead to weight gain and negatively impact heart health, which is counterproductive for someone with hypertension.

5. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?

• A. Capillary refill of 1 second
• B. Capillary refill of 5 seconds
• C. Pitting edema
• D. Shortness of breath

Correct answer: B

Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.

Similar Questions