Nursing Elites

1. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

2. A nurse is providing education to a client who is at 28 weeks gestation and has gestational diabetes mellitus. Which of the following statements should the nurse make?

• A. You will need to increase your protein intake during pregnancy.
• B. It is important to monitor your blood glucose levels closely.
• C. Gestational diabetes can increase the risk of developing type 2 diabetes later in life.
• D. You will need to avoid exercise while managing your blood sugar.

Correct answer: C

Rationale: The correct statement the nurse should make is that gestational diabetes can increase the risk of developing type 2 diabetes later in life. This information is crucial for the client's understanding of the potential long-term implications of gestational diabetes. Monitoring blood glucose levels closely (Choice B) is also important but does not address the long-term risk of developing type 2 diabetes. Choices A and D are incorrect as increasing protein intake during pregnancy and avoiding exercise are not recommended strategies for managing gestational diabetes.

3. A nurse is assessing a client who has just returned from surgery and is experiencing acute pain. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Diaphoresis.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common response to acute pain due to increased sympathetic nervous system activity. Options A and B, Bradycardia and Hypotension, are unlikely findings in a client experiencing acute pain as pain usually triggers an increase in heart rate (tachycardia) and blood pressure. Option D, Hyperactive bowel sounds, is not typically associated with acute pain.

4. What is the appropriate intervention when a patient experiences a fall?

• A. Assess for injuries
• B. Call for help
• C. Document the fall
• D. Notify the healthcare provider

Correct answer: A

Rationale: The appropriate intervention when a patient experiences a fall is to assess for injuries. This immediate action helps in identifying any harm or complications resulting from the fall, allowing for timely intervention. Calling for help may be necessary after assessing the injuries, but the priority is to evaluate the patient's condition. Documenting the fall is important for record-keeping purposes but should come after ensuring the patient's safety. Notifying the healthcare provider can be done once the assessment has been completed and any necessary initial interventions have been initiated.

5. What is the best intervention for a patient experiencing severe hypoglycemia?

• A. Administer IV dextrose
• B. Administer oral glucose
• C. Monitor blood sugar levels
• D. Recheck blood sugar in 15 minutes

Correct answer: A

Rationale: The best intervention for a patient experiencing severe hypoglycemia is to administer IV dextrose. This intervention is necessary to rapidly raise blood sugar levels in critical situations. Administering oral glucose may not be effective in severe cases as the patient may be unable to consume it. Monitoring blood sugar levels and rechecking blood sugar in 15 minutes are important steps but not the initial best intervention for severe hypoglycemia.

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