Nursing Elites

1. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?

• A. Apply a moisturizing cream to the affected areas.
• B. Encourage the client to consume foods rich in vitamin B.
• C. Notify the healthcare provider for further evaluation.
• D. Ensure that the client gets adequate B vitamins in foods or supplements.

Correct answer: D

Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.

2. The healthcare provider is caring for a client with Guillain-Barré syndrome. Which assessment finding requires the healthcare provider's immediate action?

• A. Loss of deep tendon reflexes.
• B. Ascending weakness.
• C. New onset of confusion.
• D. Decreased vital capacity.

Correct answer: D

Rationale: Decreased vital capacity is the most critical assessment finding in a client with Guillain-Barré syndrome as it indicates respiratory compromise. This requires immediate intervention to ensure adequate ventilation and prevent respiratory failure, a common complication of this syndrome. Monitoring and maintaining respiratory function are vital in these clients to prevent complications such as respiratory distress, hypoxia, and respiratory failure. Loss of deep tendon reflexes and ascending weakness are typical manifestations of Guillain-Barré syndrome but do not require immediate action compared to compromised respiratory function. New onset of confusion may be a concern but is not as immediately life-threatening as decreased vital capacity.

3. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your intake of foods high in potassium.
• C. Take the medication with a high-fiber meal to enhance absorption.
• D. Skip a dose if you feel dizzy or lightheaded.

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

4. A client diagnosed with dementia is disoriented, wandering, has a decreased appetite, and is having trouble sleeping. What is the priority nursing problem for this client?

• A. Disturbed thought processes.
• B. Altered sleep pattern.
• C. Imbalanced nutrition: less than.
• D. Risk for injury.

Correct answer: D

Rationale: The correct answer is 'Risk for injury.' In a client with dementia who is disoriented, wandering, and experiencing sleep disturbances, the priority nursing problem is the risk for injury. Disorientation and wandering behavior can lead to accidents, falls, or other harmful situations, making it crucial for the nurse to address the safety concerns first to prevent any potential harm to the client.

5. A patient with rheumatoid arthritis is prescribed methotrexate. What is an important teaching point for the nurse to provide?

• A. Take folic acid supplements as prescribed.
• B. Avoid alcohol completely.
• C. Expect to see immediate results.
• D. Limit fluid intake to 1 liter per day.

Correct answer: A

Rationale: The correct teaching point for a patient prescribed methotrexate is to take folic acid supplements as prescribed. Methotrexate can lead to a folate deficiency, which is why supplementing with folic acid is essential to reduce the risk of side effects such as mouth sores, nausea, and liver problems.

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