Nursing Elites

1. An 85-year-old client complains of generalized muscle aches and pains. What should be the nurse's first action?

• A. Assess the severity and location of the pain
• B. Obtain an order for an analgesic
• C. Reassure the client that this is not unusual for his age
• D. Encourage the client to increase activity

Correct answer: A

Rationale: The correct answer is to assess the severity and location of the pain. This is crucial because understanding the nature of the pain will guide the nurse in developing an appropriate pain management plan. Choice B is incorrect because administering analgesics should come after assessing the pain to ensure the right medication is given. Choice C is incorrect because dismissing the pain as a normal part of aging without proper assessment could overlook underlying issues. Choice D is incorrect as increasing activity without understanding the cause of pain may exacerbate the client's condition.

2. A nurse is reinforcing teaching with a client who has a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?

• A. Eggs
• B. Grapes
• C. Pasta
• D. Dried fruits

Correct answer: A

Rationale: The correct answer is A: Eggs. Eggs are a good protein source and are less likely to cause blockage or odor issues in clients with colostomies. Grapes, pasta, and dried fruits can be problematic for individuals with colostomies as they may cause digestive issues, blockages, or increased gas production. Grapes have skins that are hard to digest, pasta can cause constipation or blockage, and dried fruits are high in fiber which can lead to blockages.

3. The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important?

• A. Avoid chocolate and cheese
• B. Take frequent naps
• C. Take the medication with milk
• D. Avoid walking without assistance

Correct answer: A

Rationale: The correct answer is to avoid chocolate and cheese. MAO inhibitors can interact with tyramine-rich foods like these, potentially leading to severe hypertension. Choices B, C, and D are incorrect because taking frequent naps, taking the medication with milk, and avoiding walking without assistance are not relevant precautions associated with MAO inhibitors.

4. A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

• A. Decreased deep-tendon reflexes
• B. Skeletal muscle weakness
• C. Hypoactive bowel sounds
• D. Tingling of the lips

Correct answer: D

Rationale: The correct answer is D, tingling of the lips (perioral tingling). This is a common symptom of hypocalcemia due to increased neuromuscular excitability. Choice A, decreased deep-tendon reflexes, is more indicative of hypercalcemia. Choice B, skeletal muscle weakness, is associated with hypokalemia. Choice C, hypoactive bowel sounds, is not a typical finding in hypocalcemia.

5. A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares the elimination of which element?

• A. Sodium
• B. Potassium
• C. Phosphate
• D. Albumin

Correct answer: B

Rationale: The correct answer is B: Potassium. Spironolactone is a potassium-sparing diuretic, which means it helps retain potassium while eliminating sodium. This is beneficial for patients with cirrhosis and ascites as they are at risk of low potassium levels. Choice A, Sodium, is incorrect as Spironolactone does not spare the elimination of sodium but rather helps eliminate it. Choice C, Phosphate, is incorrect as Spironolactone does not directly affect phosphate levels. Choice D, Albumin, is incorrect as Spironolactone does not spare the elimination of albumin.

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