Nursing Elites

1. A 35-year-old Latin-American client wishes to lose weight to reduce her chances of developing heart disease and diabetes. The client states, "I do not know how to make my diet work with the kind of foods that my family eats."? What should the nurse do first to help the client determine a suitable diet for disease prevention?

• A. Provide her with copies of the approved dietary guidelines from the American Diabetic Association and the American Heart Association.
• B. Ask the client to provide a list of the types of foods she eats to determine how to best meet her needs.
• C. Provide a high-protein diet plan for the client.
• D. Provide the client with information related to risk factors for heart disease and diabetes.

Correct answer: B

Rationale: The correct answer is to ask the client to provide a list of the types of foods she eats to determine how to best meet her needs. Assessment is the first step in helping the client establish a suitable diet for disease prevention. By understanding the client's current dietary habits, the nurse can tailor recommendations based on the approved dietary guidelines from the American Diabetic Association and the American Heart Association. Providing a high-protein diet plan without assessing the client's current diet may not align with her cultural preferences or health goals. While educating the client on risk factors for heart disease and diabetes is essential, it is not the initial step in developing a personalized dietary plan.

2. In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?

• A. measles, polio, pertussis, hepatitis B
• B. diphtheria, pertussis, polio, tetanus
• C. rubella, polio, pertussis, hepatitis A
• D. measles, mumps, rubella, polio

Correct answer: B

Rationale: By 12 months of age, children should have received the DTaP (diphtheria, pertussis, and tetanus) vaccine along with the polio vaccine. The MMR (measles, mumps, and rubella) vaccine is not typically given until the child is 12-15 months old. Therefore, option B is correct as it includes vaccines that are usually administered by 12 months of age. Options A, C, and D are incorrect as they include vaccines that are typically given after 12 months of age.

3. The LPN is admitting a client to the unit, and the client has rapidly blinking eyes, a stuck-out tongue, and a distorted posture. Which of these medications is the client most likely taking?

• A. Clozapine
• B. Fluoxetine
• C. Ondansetron
• D. Haloperidol

Correct answer: D

Rationale: The correct answer is Haloperidol. Haloperidol is a first-generation antipsychotic that blocks dopamine receptors and is most likely to cause extrapyramidal symptoms (EPS), such as tardive dyskinesia. Symptoms of tardive dyskinesia include rapid blinking, mouth movements, sticking out the tongue, rapid body movements, and a distorted posture. Haloperidol is associated with a higher risk of EPS compared to other antipsychotic medications like Clozapine. Clozapine is known for having a lower risk of causing EPS. Fluoxetine is a selective serotonin reuptake inhibitor used for depression and anxiety, not typically associated with these movement disorder symptoms. Ondansetron is an antiemetic used to prevent nausea and vomiting, not linked to these extrapyramidal symptoms.

4. A nurse is conducting a psychosocial assessment of a young adult. Which observations would lead the nurse to determine that the client is demonstrating a sign of emotional health?

• A. The young adult is sensitive to criticism.
• B. The young adult verbalizes unrealistic fears.
• C. The young adult verbalizes disappointment with life.
• D. The young adult verbalizes satisfaction with friendships.

Correct answer: D

Rationale: The correct answer is that the young adult verbalizes satisfaction with friendships. Emotional health in young adults is characterized by various positive signs, including satisfaction with social interactions and friendships. Expressing contentment with friendships indicates a healthy emotional state, fostering positive social connections. On the other hand, sensitivity to criticism, verbalizing unrealistic fears, and expressing disappointment with life are all indicative of emotional distress and potential mental health challenges. These behaviors can hinder social relationships and overall emotional well-being.

5. A nurse assisting with data collection for a client with kidney failure notes that the client has the appearance of generalized edema over the entire body. The nurse documents this finding using which terminology?

• A. Anasarca
• B. Ecchymosis
• C. Unilateral edema
• D. Increased vascularity of the skin tissue

Correct answer: A

Rationale: The correct term for generalized edema over the entire body is 'Anasarca.' Anasarca is indicative of a systemic issue such as congestive heart failure or kidney failure. It does not refer to increased vascularity of the skin tissue. Ecchymosis is a bruise caused by capillary bleeding into the tissues, unrelated to generalized edema. Unilateral edema is swelling in a specific area of the body, not the generalized edema observed in anasarca.

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