Nursing Elites

1. A nurse is caring for an older adult client who is confused and continually grabs at the nurse. Which of the following is a nursing action?

• A. Firmly tell the client not to grab
• B. Redirect the client’s attention
• C. Use physical restraints
• D. Avoid contact with the client

Correct answer: B

Rationale: Redirecting the client's attention is the appropriate nursing action in this scenario. When dealing with a confused client exhibiting grabbing behavior, redirection can help shift their focus to a more appropriate activity or object. Firmly telling the client not to grab may escalate the situation and create a confrontational environment, which is not recommended when caring for confused clients. The use of physical restraints should be a last resort and only implemented after all other strategies have been exhausted, as they can contribute to increased agitation and distress in older adults. Avoiding contact with the client is not a proactive approach to managing the behavior and may lead to feelings of neglect or abandonment in the client.

2. A client has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Abdominal cramping
• B. Increased thirst
• C. Elevated blood pressure
• D. Elevated heart rate

Correct answer: A

Rationale: Abdominal cramping is a common manifestation of hyponatremia (low sodium levels). When sodium levels drop, it can lead to changes in the body's water balance, affecting cell function and causing symptoms like abdominal cramping. Increased thirst (choice B) is more commonly associated with hypernatremia (high sodium levels) due to the body's attempt to dilute the excess sodium. Elevated blood pressure (choice C) and elevated heart rate (choice D) are not typically direct manifestations of low sodium levels and are more commonly seen in conditions like dehydration or shock.

3. A client with a history of hypertension is prescribed a low-sodium diet. Which food should the LPN/LVN recommend the client avoid?

• A. Fresh fruits
• B. Grilled chicken
• C. Whole grain bread
• D. Canned soup

Correct answer: D

Rationale: The correct answer is D, canned soup. Canned soups are often high in sodium content, which can be harmful to individuals with hypertension following a low-sodium diet. Fresh fruits, grilled chicken, and whole grain bread are generally healthier options with lower sodium content and can be included in a low-sodium diet. Fresh fruits provide essential vitamins and minerals, grilled chicken is a lean protein source, and whole grain bread offers fiber and nutrients without excessive sodium levels. Avoiding canned soup aligns with the goal of reducing sodium intake to manage hypertension.

4. During assessment, what is a nurse monitoring when assessing body alignment?

• A. The relationship of one body part to another in different positions
• B. The coordination between musculoskeletal and nervous systems
• C. The force opposing movement direction
• D. The ability to move freely

Correct answer: A

Rationale: When a nurse assesses body alignment, they are observing the relationship of one body part to another in various positions. This involves evaluating the positioning of joints, tendons, ligaments, and muscles while a person is standing, sitting, or lying down. Choice B is incorrect because it refers more to the coordination between the musculoskeletal and nervous systems, which is not specifically related to body alignment assessment. Choice C is incorrect as it describes the force opposing movement rather than body alignment. Choice D is incorrect as it defines the ability to move freely, which is not directly related to monitoring body alignment.

5. When a client decides not to have surgery despite significant blockages of the coronary arteries, it is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Nonmaleficence

Correct answer: B

Rationale: The correct answer is autonomy. Autonomy is the ethical principle that upholds an individual's right to make decisions about their healthcare, including the choice to refuse treatment or surgery. In this scenario, the client's decision not to have surgery despite the recommendation is an exercise of autonomy. Choice A, fidelity, refers to being faithful and keeping promises, which is not applicable in this situation. Choice C, justice, pertains to fair and equal distribution of resources and treatment, not the individual's right to make decisions. Choice D, nonmaleficence, relates to the obligation to do no harm, which is not directly applicable to the client's decision to refuse surgery.

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