Nursing Elites

1. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?

• A. Dependent edema.
• B. Ascites.
• C. Nocturia.
• D. Orthopnea.

Correct answer: D

Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.

2. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?

• A. Leave the body as is, no preparation needed
• B. Bathe the body and place ID tags on it
• C. Remove dentures before bathing the body
• D. Position the body with its head down and arms folded on its chest

Correct answer: B

Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.

3. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client’s attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.

4. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner had AIDS.
• D. Consult with the healthcare provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.

5. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

• A. Monitor daily urine output volume
• B. Drink plenty of water whenever thirsty
• C. Use salt tablets for sodium content
• D. Review food labels for sodium content

Correct answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

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