Nursing Elites

1. In planning nursing care for a bedfast client, which factor is most likely to contribute to the development of deep vein thrombosis (DVT) in an immobile client?

• A. Atherosclerotic plaque formation.
• B. Stasis of blood flow.
• C. Endothelial damage.
• D. Atherosclerotic vessel changes.

Correct answer: B

Rationale: The correct answer is B: Stasis of blood flow. Stasis of blood flow in immobile clients increases the risk of DVT, as lack of movement can cause blood to pool and clot. Atherosclerotic plaque formation (choice A) and atherosclerotic vessel changes (choice D) are more related to arterial diseases rather than DVT. Endothelial damage (choice C) can contribute to the development of DVT, but in an immobile client, stasis of blood flow is the most significant factor.

2. What are priority nursing interventions designed to do for a 4-year-old child with cerebral palsy?

• A. Assist with referral to specialized education.
• B. Support the child with independent toileting.
• C. Assist the child to develop effective communication.
• D. Encourage the child to ambulate independently.

Correct answer: C

Rationale: The correct answer is C: 'Assist the child to develop effective communication.' Children with cerebral palsy often face challenges with communication skills. Therefore, priority nursing interventions aim to help them improve their communication abilities. Choice A is incorrect because while education is important, the priority for a child with cerebral palsy is to address immediate needs. Choice B is incorrect as toileting, although important, is not the priority in this case. Choice D is incorrect as ambulation may not be feasible or the most critical concern for a child with cerebral palsy.

3. Which dietary modification is most appropriate for a client with nephrotic syndrome?

• A. High protein, low sodium
• B. Low protein, high sodium
• C. High protein, high potassium
• D. Low protein, low sodium

Correct answer: D

Rationale: The most appropriate dietary modification for a client with nephrotic syndrome is a low protein, low sodium diet. This diet helps reduce the workload on the kidneys and manage edema, which are common issues in nephrotic syndrome. Choice A, high protein, low sodium, is not recommended because excessive protein intake can further strain the kidneys. Choice B, low protein, high sodium, is inappropriate as high sodium can worsen fluid retention and hypertension. Choice C, high protein, high potassium, is not ideal as high potassium levels can be problematic for individuals with kidney issues.

4. The client with osteoporosis is being taught about dietary modifications by the nurse. Which food should the nurse recommend to increase calcium intake?

• A. Broccoli
• B. Chicken breast
• C. White bread
• D. Apple

Correct answer: A

Rationale: Broccoli is the correct answer as it is a good source of calcium, which is essential for clients with osteoporosis. Broccoli is a green leafy vegetable that provides a significant amount of calcium. Chicken breast, white bread, and apple do not contain as much calcium as broccoli and therefore are not the best choices to recommend for increasing calcium intake in clients with osteoporosis.

5. Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?

• A. Avoid cold temperatures completely.
• B. Take medications only during flare-ups.
• C. Wear gloves when removing packages from the freezer.
• D. Limit physical activity to avoid stress.

Correct answer: C

Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.

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