Nursing Elites

1. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?

• A. Disturbed thought processes.
• B. Altered sleep pattern.
• C. Imbalanced nutrition: less than.
• D. Risk for injury.

Correct answer: D

Rationale: The correct answer is 'Risk for injury.' In a client with dementia who is disoriented, wandering, and experiencing sleep disturbances, the priority nursing problem is the risk for injury. Disorientation and wandering behavior can lead to accidents, falls, or other harmful situations, making it crucial for the nurse to address the safety concerns first to prevent any potential harm to the client.

2. What is the primary goal of care for a client experiencing esophageal varices secondary to liver cirrhosis?

• A. Preventing infection
• B. Controlling bleeding
• C. Reducing portal hypertension
• D. Maintaining nutritional status

Correct answer: B

Rationale: The primary goal of care for a client with esophageal varices secondary to liver cirrhosis is to control bleeding. Esophageal varices are fragile, enlarged veins in the esophagus that can rupture and lead to life-threatening bleeding. Controlling bleeding is crucial to prevent severe complications and ensure the client's safety and well-being. Preventing infection (Choice A) is important but not the primary goal in this case. Reducing portal hypertension (Choice C) is a long-term goal that may help prevent variceal bleeding but is not the immediate priority. Maintaining nutritional status (Choice D) is essential for overall health but is secondary to controlling bleeding in this critical situation.

3. When a client reports being allergic to penicillin, which question should the nurse ask to gather more information?

• A. Are you allergic to any other medications?
• B. How often have you taken penicillin in the past?
• C. Is anyone else in your family allergic to penicillin?
• D. What happens to you when you take penicillin?

Correct answer: D

Rationale: Questioning the client about the specific allergic reaction to penicillin is crucial for assessing the severity and type of allergic response, aiding in determining appropriate treatment and avoiding potential adverse reactions.

4. A client with osteoporosis is being discharged home. Which instruction should the nurse include in the discharge teaching?

• A. Avoid weight-bearing exercises.
• B. Take calcium supplements with meals.
• C. Limit vitamin D intake.
• D. Increase intake of caffeine-containing beverages.

Correct answer: B

Rationale: Taking calcium supplements with meals is a crucial instruction for a client with osteoporosis. Calcium absorption is enhanced when taken with food, and proper calcium intake is essential for managing osteoporosis effectively by promoting bone health and density. Avoiding weight-bearing exercises (Choice A) is incorrect because these exercises help improve bone strength. Limiting vitamin D intake (Choice C) is also incorrect as vitamin D is necessary for calcium absorption. Increasing caffeine intake (Choice D) is not recommended as caffeine can interfere with calcium absorption.

5. What dietary advice should the nurse provide to help reduce the occurrence of hot flashes in a post-menopausal client?

• A. Increase intake of spicy foods.
• B. Limit caffeine and alcohol consumption.
• C. Consume a high-protein diet.
• D. Eat more dairy products.

Correct answer: B

Rationale: Limiting caffeine and alcohol consumption is recommended to help reduce the frequency of hot flashes in post-menopausal individuals. Caffeine and alcohol can trigger hot flashes and worsen their occurrence. Encouraging the client to reduce these stimulants in their diet may help alleviate hot flashes and improve their quality of life.

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