Nursing Elites

1. A nurse is reinforcing teaching with a client who has Crohn's disease about foods to include in her diet. Which of the following foods should the nurse include in the teaching?

• A. Vanilla milkshake
• B. Buttered popcorn
• C. Broccoli
• D. Grilled chicken breast

Correct answer: D

Rationale: Grilled chicken breast is a high-protein, low-fiber food that is well-tolerated by clients with Crohn's disease. Crohn's disease is an inflammatory bowel disease that often requires a low-fiber diet to reduce irritation to the digestive tract. Vanilla milkshake is high in dairy and sugar content, which may trigger symptoms in some individuals with Crohn's disease. Buttered popcorn and broccoli are high in fiber, which can be difficult for individuals with Crohn's disease to digest and may exacerbate symptoms.

2. A healthcare professional assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?

• A. Flaccid paralysis
• B. Pupils fixed and dilated
• C. Diminished spinal reflexes
• D. Reduced sensory responses

Correct answer: B

Rationale: The correct answer is B: Pupils fixed and dilated. Fixed and dilated pupils are a critical neurological sign that indicates severe neurological damage or brain herniation, posing a significant concern for the patient's condition. Flaccid paralysis (choice A) typically indicates lower motor neuron injury, while diminished spinal reflexes (choice C) and reduced sensory responses (choice D) may suggest various neurological issues but are not as acutely concerning as fixed and dilated pupils in this scenario.

3. A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?

• A. Auscultation of breath sounds
• B. Measurement of peak expiratory flow
• C. Observation of the client's use of accessory muscles
• D. Assessment of the client's skin color

Correct answer: A

Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.

4. The healthcare provider should recognize which of the following as an indication of dehydration in an elderly client?

• A. Skin turgor
• B. Dry mucous membranes
• C. Elevated temperature
• D. Increased pulse pressure

Correct answer: B

Rationale: Dry mucous membranes are a classic sign of dehydration, especially in elderly individuals. Dehydration can lead to decreased moisture in the mucous membranes, making them dry. Skin turgor, although commonly assessed for dehydration in younger individuals, may be less reliable in the elderly due to changes in skin elasticity. Elevated temperature is more indicative of an infection or other conditions. Increased pulse pressure is not typically associated with dehydration in the elderly.

5. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise by doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: The most important instruction for a 65-year-old female client diagnosed with osteoporosis regarding exercise is to engage in weight-bearing activities. Weight-bearing exercises are crucial in maintaining bone density and preventing osteoporosis-related fractures. Choice B is incorrect because the primary focus should be on bone health rather than weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture would limit physical activity, which is essential for overall health. Choice D is incorrect as while strengthening muscles is beneficial, weight-bearing activities directly impact bone health in osteoporosis.

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