Nursing Elites

1. A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:

• A. within normal limits, so a weight-reduction diet is unnecessary
• B. lower than normal, so education about nutrient-dense foods is needed
• C. indicating obesity because the BMI is 35
• D. indicating overweight status because the BMI is 27

Correct answer: C

Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Choices A, B, and D are incorrect because the client's BMI is above 30, which falls under the obesity category. Therefore, a weight-reduction diet and increased physical activity are necessary to address the client's weight status and promote overall health.

2. Which client should be seen first by the Emergency Department nurse?

• A. A six-year-old with a femur fracture.
• B. A two-year-old with a fever of 102 degrees F.
• C. A three-year-old with wheezes in the right lower lobe.
• D. A two-year-old whose gastrostomy tube came out.

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

3. Which instruction should be given in a health education class regarding testicular cancer?

• A. All males should perform a testicular exam after a warm bath or shower.
• B. Testicular exams should be performed on a daily basis.
• C. Reddening or darkening of the scrotum is a normal finding.
• D. Testicular exams should be performed after a warm bath or shower.

Correct answer: D

Rationale: The correct instruction for testicular cancer education is that testicular exams should be performed after a warm bath or shower as it relaxes the scrotum and makes the exam easier. Testicular exams should be done monthly by all men starting around age 15, not after the age of 30 (Choice A) or on a daily basis (Choice B), which is unnecessary and may lead to unnecessary anxiety. Reddening or darkening of the scrotum is not a normal finding (Choice C) and should be reported to a healthcare provider for further evaluation.

4. A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?

• A. Seizures
• B. Muscle weakness
• C. Depression
• D. Anxiety

Correct answer: B

Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.

5. A patient has been prescribed Tegretol for the first time. Which of the following side effects is not associated with Tegretol?

• A. Sore throat
• B. Vertigo
• C. Fever
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'Shortness of breath.' Side effects commonly associated with Tegretol include sore throat, vertigo, and fever. Shortness of breath is not a typical side effect of Tegretol use. Sore throat, vertigo, and fever are known side effects of Tegretol, while shortness of breath is not typically linked to its use.

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