Nursing Elites

1. A client who is to undergo a colonoscopy is being taught by a nurse about the procedure. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will drink liquids right up until the procedure.
• B. I will need to stop eating and drinking at least 24 hours before the procedure.
• C. I will be sedated and will not feel any pain during the procedure.
• D. I will not need to follow any specific dietary restrictions for this procedure.

Correct answer: C

Rationale: Choice C is the correct answer. During a colonoscopy, clients are typically sedated, so they do not feel any pain during the procedure. Choices A, B, and D are incorrect. Clients are usually required to stop eating and drinking at least 24 hours before a colonoscopy, and there are specific dietary restrictions that need to be followed before the procedure to ensure a successful examination.

2. A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?

• A. Nausea
• B. Confusion about own name
• C. Rapid pulse
• D. Vomiting

Correct answer: B

Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.

3. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

4. Which dietary instruction is appropriate for a client with chronic kidney disease?

• A. Increase the intake of potassium
• B. Limit the intake of phosphorus-rich foods
• C. Encourage the intake of protein-rich foods
• D. Advise the client to increase fluid intake

Correct answer: B

Rationale: Limiting the intake of phosphorus-rich foods is appropriate for a client with chronic kidney disease. In individuals with chronic kidney disease, the kidneys cannot filter phosphorus effectively, leading to a buildup in the blood. This can result in bone and heart problems. Therefore, reducing phosphorus intake is crucial to prevent complications. Choices A, C, and D are incorrect. Increasing potassium intake may be harmful as potassium levels can accumulate in the blood with impaired kidney function. Encouraging protein-rich foods may not be suitable as excessive protein intake can strain the kidneys. Advising to increase fluid intake should be done cautiously as individuals with chronic kidney disease may need to restrict fluids based on their stage of the disease.

5. What are the signs and symptoms of Cushing's syndrome, and how should they be managed?

• A. Weight gain, moon face; administer corticosteroids
• B. Hirsutism and thin extremities; manage with diuretics
• C. Purple striae, muscle weakness; provide dietary counseling
• D. Hypertension and bruising; manage with fluid restriction

Correct answer: A

Rationale: The correct signs and symptoms of Cushing's syndrome are weight gain and a moon face. Corticosteroids are used to manage Cushing's syndrome by reducing the overproduction of cortisol. Choice B is incorrect because hirsutism and thin extremities are not typical signs of Cushing's syndrome. Choice C is incorrect as purple striae and muscle weakness are more characteristic of the syndrome. Choice D is also incorrect as hypertension and bruising are not primary signs of Cushing's syndrome.

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