Nursing Elites

1. After a few hours in the Emergency Room, Mr. Dizon is admitted to the ward with an order of hourly monitoring of blood pressure. The nurse finds that the cuff is too narrow and this will cause the blood pressure reading to be:

• A. inconsistent
• B. low systolic and high diastolic
• C. higher than what the reading should be
• D. lower than what the reading should be

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. Age group categories within older adults are classified as 'young old,' 'old,' and 'oldest old,' the latter of which comprises adults aged _____.

• A. 70-80 years
• B. 75-84 years
• C. 80-90 years
• D. 85 years or older

Correct answer: D

Rationale: The 'oldest old' category includes adults aged 85 years or older. This age group faces unique health challenges and requires specialized care. Choices A, B, and C are incorrect as they do not fall within the age range specified for the 'oldest old' category.

3. What is the most important concern immediately after a myocardial infarction?

• A. Reducing cholesterol intake
• B. Allowing cardiac rest for healing
• C. Reducing saturated fat intake
• D. Eating several small meals each day

Correct answer: B

Rationale: Immediately after a myocardial infarction, the primary concern is to allow the heart to rest and heal to prevent further damage. This is why choice B is the correct answer. While choices A, C, and D might be a part of the long-term management plan following a myocardial infarction, they are not the immediate priority. Reducing cholesterol and saturated fat intake, as well as adjusting eating habits can help prevent future heart issues, but do not directly contribute to the immediate recovery post-myocardial infarction.

4. What is the procedure called when direct observations are used to generate an estimate of a client's current food intake?

• A. Food diary
• B. 24-hour recall
• C. Kilocalorie count
• D. Nutrient surveillance record

Correct answer: C

Rationale: A kilocalorie count is the correct answer as it involves directly observing a client's food intake, which is often used in hospitals to accurately assess nutritional intake and ensure it meets dietary requirements. A food diary (Choice A) is typically self-reported by the client and not directly observed. A 24-hour recall (Choice B) is also usually self-reported and relies on a client's memory of the past 24 hours, which can be unreliable. A nutrient surveillance record (Choice D) is a broader term for tracking nutrient intake in a population and is not specific to the direct observation of an individual's food intake.

5. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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