Nursing Elites

1. An appropriate nursing diagnosis for clients in the acute manic phase of bipolar disorder is:

• A. Risk for injury directed to self
• B. Risk for injury directed to others
• C. Impaired nutrition less than body requirements
• D. Ineffective individual coping

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

2. Which of the following is not a desirable blood lipid value?

• A. low total cholesterol
• B. high LDL
• C. high HDL
• D. low blood triglycerides

Correct answer: B

Rationale: The correct answer is B. High levels of LDL (low-density lipoprotein) cholesterol are undesirable as they are associated with an increased risk of cardiovascular disease. Therefore, low total cholesterol (choice A), high HDL (choice C), and low blood triglycerides (choice D) are considered desirable blood lipid values. Low total cholesterol is beneficial as high levels can increase the risk of heart disease. High HDL cholesterol is considered good as it helps remove LDL cholesterol from the arteries. Low blood triglycerides are also preferred as high levels are associated with an increased risk of heart disease.

3. Which of the following methods is the best method for determining nasogastric tube placement in the stomach?

• A. X-ray
• B. Observation of gastric aspirate
• C. Testing of pH of gastric aspirate
• D. Placement of external end of tube under water

Correct answer: A

Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.

4. Nurse DMLM is correct in identifying the correct sequence of events during abdominal assessment if she identifies which of the following?

• A. Inspection, Auscultation, Percussion, Palpation
• B. Inspection, Percussion, Palpation, Auscultation
• C. Inspection, Palpation, Percussion, Auscultation
• D. Inspection, Auscultation, Palpation, Percussion

Correct answer: D

Rationale: The correct sequence for abdominal assessment is Inspection, Auscultation, Percussion, Palpation. Start with Inspection to observe any visible abnormalities, followed by Auscultation to listen for bowel sounds, then Percussion to assess the density of underlying structures, and finally Palpation to feel for any tenderness or masses. Choices A, B, and C have the incorrect sequence of assessment techniques.

5. A client who is experiencing dumping syndrome following gastric surgery is receiving education from a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should drink additional fluids with my meals.
• B. I should eat high-fiber snacks between meals.
• C. I should eat a protein source with each meal.
• D. I can have caffeinated beverages in small amounts.

Correct answer: C

Rationale: The correct answer is C. Eating a protein source with each meal can help manage dumping syndrome by slowing gastric emptying and reducing symptoms. This choice is the most appropriate as it directly addresses a key dietary recommendation for dumping syndrome. Choices A, B, and D are incorrect because drinking additional fluids with meals, eating high-fiber snacks between meals, and consuming caffeinated beverages can exacerbate dumping syndrome symptoms by increasing gastric emptying and worsening the condition.

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