Nursing Elites

1. A client has been diagnosed with hyperthyroidism. Which of these nursing diagnoses should receive the highest priority?

• A. Risk for injury related to exophthalmos
• B. Impaired social interaction related to emotional lability
• C. Imbalanced nutrition: Less than body requirements related to hypermetabolism
• D. Activity intolerance related to fatigue

Correct answer: D

Rationale: The correct answer is 'D: Activity intolerance related to fatigue.' This nursing diagnosis should receive the highest priority for a client with hyperthyroidism. Hyperthyroidism often leads to symptoms such as fatigue, weakness, and muscle discomfort, which can significantly impact the client's ability to perform daily activities. Addressing activity intolerance is crucial to prevent exacerbation of symptoms and promote the client's overall well-being. Choices A, B, and C are important nursing diagnoses as well, but in the context of hyperthyroidism, addressing activity intolerance takes precedence over the risk for injury related to exophthalmos, impaired social interaction related to emotional lability, and imbalanced nutrition due to hypermetabolism.

2. A nurse is contributing to the plan of care of a client who has had a stroke. The client is experiencing severe dysphagia with choking and coughing while eating. Which of the following nutritional therapies should the nurse expect to include in the plan of care?

• A. NPO until dysphagia subsides
• B. Supplements via NG tube
• C. Initiation of total parenteral nutrition
• D. Mechanical soft diet

Correct answer: D

Rationale: The correct answer is D: Mechanical soft diet. A mechanical soft diet is appropriate for clients with severe dysphagia as it helps reduce the risk of choking and aspiration by providing food that is easier to swallow. Choice A, NPO until dysphagia subsides, may be necessary initially but is not a long-term solution. Choice B, supplements via NG tube, may be considered if the client is unable to meet their nutritional needs orally, but it does not address the texture modification needed for dysphagia. Choice C, initiation of total parenteral nutrition, is typically reserved for clients who cannot tolerate any oral intake and is not the first-line option for dysphagia management.

3. While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to

• A. Call the health care provider immediately
• B. Administer acetaminophen as ordered as this is normal at this time
• C. Send blood, urine, and sputum for culture
• D. Increase the client's fluid intake

Correct answer: B

Rationale: In this scenario, the nurse should administer acetaminophen as ordered because a slight fever is normal after an MI. This intervention can help manage the fever unless other complications are present. Calling the health care provider immediately is not necessary for a slight fever post-MI. Sending blood, urine, and sputum for culture is not indicated solely based on a slight fever without other symptoms or signs of infection. Increasing fluid intake may be beneficial for various reasons but is not the priority in this situation where managing the fever with acetaminophen is appropriate.

4. A nurse is reviewing a client's admission laboratory findings that indicate the client has hyponatremia. Which of the following laboratory findings should the nurse expect to be below the expected reference range?

• A. Magnesium
• B. Calcium
• C. Chloride
• D. Potassium

Correct answer: C

Rationale: The correct answer is C: Chloride. Chloride levels are typically low in cases of hyponatremia, as it often accompanies sodium loss. Magnesium (choice A) is not directly related to hyponatremia. Calcium (choice B) and Potassium (choice D) levels are usually not significantly affected by hyponatremia, making them less likely to be below the expected reference range in this scenario.

5. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise by doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: The most important instruction for a 65-year-old female client diagnosed with osteoporosis regarding exercise is to engage in weight-bearing activities. Weight-bearing exercises are crucial in maintaining bone density and preventing osteoporosis-related fractures. Choice B is incorrect because the primary focus should be on bone health rather than weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture would limit physical activity, which is essential for overall health. Choice D is incorrect as while strengthening muscles is beneficial, weight-bearing activities directly impact bone health in osteoporosis.

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