Nursing Elites

1. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)

• A. Obtain the pulses in all four extremities
• B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
• C. Determine the client’s orientation to person, place, and time
• D. B, C

Correct answer: D

Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.

2. People who use monoamine oxidase inhibitors for the treatment of depression need to avoid foods high in:

• A. Folate
• B. Tyramine
• C. Potassium
• D. Vitamin K

Correct answer: B

Rationale: The correct answer is B: Tyramine. When individuals taking monoamine oxidase inhibitors (MAOIs) consume foods high in tyramine, it can lead to a potentially dangerous increase in blood pressure known as a hypertensive crisis. Foods high in tyramine include aged cheeses, cured meats, and certain fermented foods. Choices A, C, and D are incorrect. Folate, potassium, and vitamin K are not typically contraindicated with the use of MAOIs.

3. Which discharge instruction should the nurse teach the client diagnosed with varicose veins who has received sclerotherapy?

• A. Walk 15 to 20 minutes three (3) times a day.
• B. Keep the legs in the dependent position when sitting.
• C. Remove compression bandages before going to bed.
• D. Perform Berger-Allen exercises (4) times a day.

Correct answer: A

Rationale: The correct answer is to instruct the client to walk 15 to 20 minutes three times a day. Walking is beneficial as it helps improve circulation and reduces the risk of complications following sclerotherapy. Choice B is incorrect because keeping the legs in the dependent position when sitting can lead to increased venous pressure, worsening varicose veins. Choice C is incorrect as compression bandages should typically be worn continuously, especially during the initial healing phase. Choice D is incorrect as Berger-Allen exercises are not commonly associated with post-sclerotherapy care.

4. A patient with Crohn’s disease is experiencing diarrhea. Which dietary recommendation is appropriate?

• A. High-fiber diet
• B. Low-residue diet
• C. High-fat diet
• D. High-protein diet

Correct answer: B

Rationale: A low-residue diet is the appropriate dietary recommendation for a patient with Crohn’s disease experiencing diarrhea. This diet helps reduce bowel movements and manage diarrhea by limiting the intake of foods that are harder to digest. High-fiber diets (Choice A) may worsen diarrhea due to increased bulk in the stool. High-fat diets (Choice C) can be harder to digest and may exacerbate symptoms. High-protein diets (Choice D) are not specifically recommended for managing diarrhea in Crohn’s disease.

5. A 31-year-old client is seeking contraceptive information. Before responding to the client’s questions about contraceptives, the nurse obtains a health history. What factor in the client’s history indicates to the nurse that oral contraceptives are contraindicated?

• A. More than 30 years of age
• B. Had two multiple pregnancies
• C. Smokes 1 pack of cigarettes a day
• D. Has a history of borderline hypertension

Correct answer: C

Rationale: The correct answer is C. Smoking, especially in clients over 30, increases the risk of thromboembolic events, making oral contraceptives contraindicated. Choice A (More than 30 years of age) is not a direct contraindication for oral contraceptives. Choice B (Had two multiple pregnancies) is not a factor that contraindicates the use of oral contraceptives. Choice D (Has a history of borderline hypertension) is not a specific contraindication for oral contraceptives unless it is severe or uncontrolled hypertension.

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