Nursing Elites

1. A nurse is caring for a client with a thiamine deficiency. Which assessment findings will the nurse expect?

• A. Tachycardia, muscle weakness, and lack of coordination
• B. Swollen lips, cracks in the corners of the mouth, and glossitis
• C. Neuropsychiatric symptoms of delusions and hallucinations
• D. Scaly rash on arms, dementia, and diarrhea

Correct answer: A

Rationale: Thiamine deficiency, also known as Vitamin B1 deficiency, can present with various symptoms. Tachycardia, muscle weakness, and lack of coordination are classic signs of thiamine deficiency due to its role in energy metabolism. Swollen lips, cracks in the corners of the mouth, and glossitis are more indicative of a deficiency in riboflavin (Vitamin B2). Neuropsychiatric symptoms of delusions and hallucinations are characteristic of niacin (Vitamin B3) deficiency. A scaly rash on the arms, dementia, and diarrhea are not typically associated with thiamine deficiency. Therefore, the correct assessment findings for a client with thiamine deficiency are tachycardia, muscle weakness, and lack of coordination.

2. A client says to the nurse “I am worthless person, I should be dead” The nurse best replies:

• A. “Don’t say you are worthless, you are not a worthless person”
• B. “We are going to help you with your feelings”
• C. “What makes you feel you’re worthless?”
• D. “What you say is not true”

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

3. The nurse is completing a nutritional assessment on a client. Which statement made by the client is most concerning to the nurse?

• A. "I notice when I take a vitamin E supplement, I bruise more easily."
• B. "I work nights and rarely go outside during the day."
• C. "I take warfarin, so I need to limit the amount of green leafy vegetables I eat."
• D. "My vitamin supplement has the recommended daily allowance of vitamin A."

Correct answer: A

Rationale: The correct answer is A. Excessive intake of vitamin E can increase the risk of bleeding as it acts as a blood thinner. Bruising easily may indicate too much vitamin E. Choice B is not as concerning as it describes a lifestyle that may lead to vitamin D deficiency due to lack of sunlight exposure. Choice C shows awareness of the interaction between warfarin and vitamin K, which is expected. Choice D indicates knowledge of the vitamin A content in the supplement, which is not a cause for concern.

4. Patients with congestive heart failure need to restrict their intake of:

• A. fiber
• B. sodium
• C. cholesterol
• D. saturated fat

Correct answer: B

Rationale: Patients with congestive heart failure need to restrict their intake of sodium. This restriction is crucial to prevent fluid retention, which can exacerbate the condition. While fiber is generally beneficial for heart health, sodium restriction is more critical in this scenario. Cholesterol and saturated fat intake should also be monitored, but sodium restriction takes precedence due to its direct impact on fluid balance.

5. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

• A. Interview the client for chief complaints and other symptoms
• B. Talk to the relatives to gather data about history of illness
• C. Do auscultation to check for chest congestion
• D. Do a physical examination while asking the client relevant questions

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

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