Nursing Elites

1. A nurse is providing care for a client with dementia who frequently wanders. What is the best strategy to ensure their safety?

• A. Use restraints to prevent wandering
• B. Encourage the client to walk in a monitored area
• C. Place a bed exit alarm system
• D. Ask family members to stay with the client at all times

Correct answer: C

Rationale: The best strategy to ensure the safety of a client with dementia who frequently wanders is to place a bed exit alarm system. This system alerts staff when the client attempts to leave the bed, reducing the risk of falls. Choice A, using restraints, is not the best approach as it can lead to complications and is not recommended unless absolutely necessary. Choice B, encouraging the client to walk in a monitored area, may not be effective in preventing wandering as the client may still wander away. Choice D, asking family members to stay with the client at all times, may not be feasible or practical, especially for round-the-clock supervision.

2. What is the priority in managing a client diagnosed with delirium?

• A. Administer anti-anxiety medication
• B. Identify any underlying causes of delirium
• C. Reduce environmental stimulation to calm the client
• D. Encourage deep breathing exercises

Correct answer: B

Rationale: The priority in managing a client diagnosed with delirium is to identify any underlying causes. Delirium can be caused by various factors such as infections, medications, or metabolic imbalances. By determining the root cause, healthcare providers can address the issue effectively and tailor the treatment plan accordingly. Administering anti-anxiety medication (Choice A) may help manage symptoms but does not address the underlying cause of delirium. Similarly, reducing environmental stimulation (Choice C) and encouraging deep breathing exercises (Choice D) may provide some relief, but they do not target the primary concern of identifying and addressing the underlying causes of delirium.

3. A nurse is admitting a client who has anorexia nervosa. Which of the following is an expected finding?

• A. Iron 90 mcg/dl.
• B. Prealbumin 10 mcg/dl.
• C. Serum creatinine 0.8 mg/dl.
• D. Calcium 9.5 mg/dl.

Correct answer: B

Rationale: Corrected Rationale: Low prealbumin levels are indicative of malnutrition, which is common in individuals with anorexia nervosa. Iron levels, serum creatinine, and calcium levels are not typically affected in the same way by anorexia nervosa, making choices A, C, and D incorrect.

4. What are the complications of untreated hypertension?

• A. Heart disease and stroke
• B. Kidney failure and vision loss
• C. Pulmonary embolism and arrhythmias
• D. Blood clots and gastrointestinal bleeding

Correct answer: A

Rationale: The correct answer is A: 'Heart disease and stroke.' Untreated hypertension can lead to various complications, including heart disease and stroke. These are common outcomes of long-term high blood pressure. Choice B, 'Kidney failure and vision loss,' is incorrect as kidney failure and vision loss are more commonly associated with diabetic complications rather than untreated hypertension. Choice C, 'Pulmonary embolism and arrhythmias,' while serious, are not among the primary complications of untreated hypertension. Choice D, 'Blood clots and gastrointestinal bleeding,' are not typical complications of untreated hypertension but can occur due to other conditions such as blood clotting disorders or gastrointestinal diseases.

5. A nurse is teaching a client who has diabetes mellitus about foot care. Which of the following instructions should the nurse include?

• A. Soak feet in hot water daily
• B. Use a heating pad on the feet daily
• C. Cut toenails straight across
• D. Massage feet with lotion daily

Correct answer: C

Rationale: The correct answer is C: 'Cut toenails straight across.' This instruction is crucial for clients with diabetes to prevent ingrown toenails and potential foot complications. Soaking feet in hot water daily (Choice A) can lead to skin damage and is not recommended for diabetic individuals. Using a heating pad on the feet daily (Choice B) can cause burns or injuries due to reduced sensation in the feet that often accompanies diabetes. Massaging feet with lotion daily (Choice D) is generally safe but may not address the specific preventive measure of cutting toenails correctly.

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