Nursing Elites

1. When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?

• A. Complete a fall-risk assessment
• B. Place a fall-risk identification bracelet on the client
• C. Provide the client with nonskid footwear
• D. Set the bed to the lowest position

Correct answer: A

Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.

2. A client has a new diagnosis of GERD. Which of the following statements should the nurse include in the teaching about dietary management?

• A. You should increase your intake of high-fat foods.
• B. You should decrease your intake of high-fat foods.
• C. You should avoid foods that contain gluten.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: The correct answer is to decrease the intake of high-fat foods. High-fat foods can exacerbate symptoms of GERD by delaying stomach emptying and increasing the risk of reflux. By reducing high-fat foods in the diet, the client can help manage symptoms of GERD and decrease the likelihood of complications. Choice A is incorrect because increasing high-fat foods can worsen GERD symptoms. Choice C is unrelated as gluten is not a specific concern for GERD. Choice D is incorrect as increasing dairy products may lead to increased fat intake, which is not recommended for GERD.

3. A client with meningitis is being assessed by a healthcare provider. Which of the following findings should the provider expect?

• A. Negative Brudzinski’s sign.
• B. Flaccid neck muscles.
• C. Petechial rash.
• D. Hypoactive deep tendon reflexes.

Correct answer: C

Rationale: A petechial rash is a characteristic finding in clients with meningitis, indicating small, pinpoint hemorrhages under the skin. This rash results from the infection's impact on the blood vessels. Petechiae are important to recognize as they can help differentiate meningitis from other conditions with similar symptoms. Brudzinski’s sign, neck stiffness, and positive Kernig’s sign are more common physical exam findings in meningitis. Flaccid neck muscles and hypoactive deep tendon reflexes are not typically associated with meningitis.

4. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

• A. Inspection, percussion, palpation, auscultation
• B. Percussion, auscultation, inspection, palpation
• C. Auscultation, palpation, inspection, percussion
• D. Inspection, auscultation, percussion, palpation

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

5. A client has a new diagnosis of hypertension and is being taught about dietary management. Which of the following client statements indicates an understanding of the teaching?

• A. I will increase my intake of dairy products.
• B. I will eat more fresh fruits and vegetables.
• C. I will limit my intake of whole grains.
• D. I will consume more red meat.

Correct answer: B

Rationale: The correct answer is B because increasing the intake of fresh fruits and vegetables can help manage blood pressure. These foods are rich in nutrients like potassium, fiber, and antioxidants, which are beneficial for individuals with hypertension. Dairy products are usually high in saturated fats, which can be detrimental to blood pressure control. Whole grains are generally recommended for their health benefits, including maintaining a healthy weight and heart health. Red meat is often high in saturated fats and can contribute to high blood pressure and other cardiovascular risks.

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