Nursing Elites

1. A client with a new diagnosis of systemic lupus erythematosus (SLE) is being cared for by a nurse. Which of the following findings should the nurse expect?

• A. Joint pain.
• B. Weight gain.
• C. Butterfly-shaped rash on the face.
• D. Increased appetite.

Correct answer: B

Rationale: The correct answer is B: Weight gain. Weight gain is a common finding in clients with systemic lupus erythematosus due to fluid retention. Joint pain (choice A) is also common in SLE but is not specific to fluid retention. A butterfly-shaped rash on the face (choice C) is a classic symptom of SLE but is not related to fluid retention. Increased appetite (choice D) is less likely in SLE compared to weight gain.

2. What is the recommended dietary restriction for a patient with chronic kidney disease?

• A. Limit potassium intake
• B. Limit fluid intake
• C. Increase protein intake
• D. Increase carbohydrate intake

Correct answer: B

Rationale: The correct answer is to limit fluid intake for a patient with chronic kidney disease. This restriction helps manage fluid balance to prevent fluid overload. Choices A, C, and D are incorrect. Limiting potassium intake is essential for some patients with kidney disease, but it is not the primary dietary restriction. Increasing protein intake is usually not recommended due to the impaired kidney function in these patients. Increasing carbohydrate intake is also not a standard recommendation for patients with chronic kidney disease.

3. A client taking haloperidol is exhibiting extrapyramidal symptoms. Which intervention should the nurse anticipate?

• A. Increase the dose of haloperidol.
• B. Administer benztropine.
• C. Administer naloxone.
• D. Monitor blood pressure before administering the next dose.

Correct answer: B

Rationale: The correct intervention for a client exhibiting extrapyramidal symptoms while taking haloperidol is to administer benztropine. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal symptoms caused by antipsychotic medications like haloperidol. Increasing the dose of haloperidol (Choice A) would exacerbate the symptoms rather than alleviate them. Administering naloxone (Choice C) is not indicated for extrapyramidal symptoms. Monitoring blood pressure (Choice D) is important but not the primary intervention for managing extrapyramidal symptoms.

4. A nurse is planning care for a client who has dementia and is frequently agitated. Which of the following interventions should the nurse include in the plan of care?

• A. Offer the client several choices when scheduling activities.
• B. Confront the client when inappropriate behavior occurs.
• C. Use a calm, reassuring approach when speaking to the client.
• D. Encourage the client to engage in stimulating activities.

Correct answer: C

Rationale: The correct intervention for a client with dementia who is frequently agitated is to use a calm and reassuring approach when speaking to them. This approach helps reduce agitation and create a more therapeutic environment. Offering several choices may overwhelm the client and increase agitation, making choice A incorrect. Confronting the client can escalate the situation and worsen agitation, making choice B inappropriate. While encouraging stimulating activities is beneficial, it may not be the most effective intervention for immediate agitation management, making choice D less priority compared to using a calm and reassuring approach.

5. A nurse is planning care for a client who has a closed head injury and has an intraventricular catheter. Which of the following interventions should the nurse include to reduce the risk for infection?

• A. Keep the head of the bed elevated to 30 degrees.
• B. Administer IV antibiotics prophylactically.
• C. Change the catheter insertion site every 24 hours.
• D. Monitor the insertion site for redness.

Correct answer: D

Rationale: The correct answer is to monitor the insertion site for redness. This intervention helps detect signs of infection early in clients with intraventricular catheters. Keeping the head of the bed elevated to 30 degrees is important for managing intracranial pressure but does not directly reduce the risk of infection. Administering IV antibiotics prophylactically is not recommended as a routine practice due to the risk of antibiotic resistance and should only be done based on culture results. Changing the catheter insertion site every 24 hours is unnecessary and increases the risk of introducing new pathogens.

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