Nursing Elites

1. A client tells the PN that she has a family history of cancer and has increased the amount of dairy products in her diet to reduce her risk of getting cancer. How should the PN respond?

• A. Encourage the client to get plenty of exercise in addition to the dietary change
• B. Provide written information about the seven warning signs of cancer
• C. Remind the client to ensure that the dairy products are fortified with Vitamin D
• D. Suggest that an increase in fruits and vegetables is more beneficial

Correct answer: D

Rationale: Increasing fruits and vegetables in the diet is more beneficial in reducing cancer risk due to their high levels of antioxidants and fiber, which help protect against cancer. While exercise is important for overall health, in this context, focusing on fruits and vegetables is more relevant to reducing cancer risk than exercise alone. Providing information about cancer warning signs is not directly addressing the client's dietary choice. While Vitamin D is essential for various health aspects, the primary focus here should be on a diet rich in fruits and vegetables for cancer risk reduction.

2. The client with schizophrenia who continues to repeat the last words heard is exhibiting a sign of disturbed thought processes. Which nursing problem should the nurse document in the medical record?

• A. Altered sensory perception
• B. Impaired social interaction
• C. Risk for self-directed violence
• D. Disturbed thought processes

Correct answer: D

Rationale: The correct answer is D: Disturbed thought processes. Echolalia, the repetition of words, is a sign of disturbed thought processes commonly seen in clients with schizophrenia. It reflects a disorganization in thinking rather than a sensory perception issue (Choice A). Impaired social interaction (Choice B) refers to difficulties in relating to others, which is not the primary concern in echolalia. Risk for self-directed violence (Choice C) focuses on potential harm to self, which is separate from the repetitive behavior of echolalia.

3. A client is post-operative day two from a total hip arthroplasty. The nurse notices the surgical wound is red and warm to the touch. What is the most appropriate action?

• A. Apply an ice pack to the incision site.
• B. Monitor the client's temperature.
• C. Document the findings and continue to monitor.
• D. Notify the healthcare provider.

Correct answer: D

Rationale: The correct action when a nurse notices redness and warmth at the surgical wound post total hip arthroplasty is to notify the healthcare provider. These signs may indicate an infection, and prompt evaluation by the healthcare provider is crucial to initiate appropriate treatment. Applying an ice pack (Choice A) may not address the underlying issue of a potential infection. Monitoring the client's temperature (Choice B) is important but not the priority when signs of infection are present. Documenting the findings and continuing to monitor (Choice C) is necessary but should be accompanied by notifying the healthcare provider for further assessment and intervention.

4. After a laparoscopic cholecystectomy, what is the most important instruction the nurse should give the client regarding post-operative care at home?

• A. Avoid lifting heavy objects for at least a week.
• B. Follow a low-fat diet.
• C. Monitor the incision sites for signs of infection.
• D. Resume normal activities as tolerated.

Correct answer: C

Rationale: Monitoring the incision sites for signs of infection is crucial after a laparoscopic cholecystectomy. Infections can lead to serious complications if not detected early. While avoiding heavy lifting and following a low-fat diet are important aspects of recovery, monitoring for infection takes precedence as it directly impacts the client's immediate post-operative well-being. Therefore, option C is the correct answer as it addresses the most critical aspect of post-operative care.

5. Which laboratory value is most important to monitor for a patient receiving heparin therapy?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Partial thromboplastin time (PTT)
• D. International normalized ratio (INR)

Correct answer: C

Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.

Similar Questions