Nursing Elites

1. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Limit sodium intake to 4 grams per day.
• B. Weigh yourself daily to monitor for fluid retention.
• C. Drink 2 liters of water each day.
• D. Increase physical activity gradually.

Correct answer: B

Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.

2. A nurse is developing a care plan for a client who has paraplegia and has an area of nonblanchable erythema over the ischium. Which intervention should the nurse include?

• A. Place the client upright on a donut-shaped cushion.
• B. Teach the client to shift his weight every 15 minutes while sitting.
• C. Turn and reposition the client every 3 hours.
• D. Assess pressure points every 24 hours.

Correct answer: B

Rationale: The correct intervention for a client with nonblanchable erythema over the ischium is to teach the client to shift his weight every 15 minutes while sitting. This action helps relieve pressure on the affected area and prevents further skin breakdown. Placing the client upright on a donut-shaped cushion (Choice A) may not address the need for frequent weight shifts. Turning and repositioning the client every 3 hours (Choice C) is important for overall skin health but may not provide adequate relief for the specific area of nonblanchable erythema. Assessing pressure points every 24 hours (Choice D) is not frequent enough to prevent worsening of the skin condition in this case.

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 healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?

• A. Nuchal rigidity.
• B. Flaccid paralysis.
• C. Bradycardia.
• D. Hypothermia.

Correct answer: A

Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.

5. What is the best intervention for a patient with constipation?

• A. Administer a stool softener
• B. Encourage fluid intake
• C. Provide a high-fiber diet
• D. Administer a laxative

Correct answer: B

Rationale: Encouraging fluid intake is the best intervention for a patient with constipation. Fluids help soften stools, making them easier to pass. While stool softeners and laxatives can also help with constipation, they are more of a short-term solution and may not address the root cause. A high-fiber diet is beneficial for preventing constipation in the long run, but in the immediate situation of constipation, fluid intake is key.

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