Nursing Elites

1. Larry, 55 years old, who is suspected of having colorectal cancer, is admitted to the CI. After taking the history and vital signs the physician does which test as a screening test for colorectal cancer.

• A. Barium enema
• B. Carcinoembryonic antigen
• C. Annual digital rectal examination
• D. Proctosigmoidoscopy

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

2. Theresa, a mother with a 2-year-old daughter, asks, 'At what age can I start taking my daughter's blood pressure as a routine procedure, since hypertension is common in our family?' What would your answer be?

• A. At 2 years old, you may
• B. As early as 1 year old
• C. When she's 3 years old
• D. When she's 6 years old

Correct answer: D

Rationale: Regular blood pressure checks generally start from age 3, but in the case of a family history of hypertension, they should start when the child is around 6 years old. This is because the readings will be more reliable and indicative of the child's health condition at this age. The other options are incorrect because they suggest earlier ages for routine blood pressure checks. While blood pressure can be measured at any age, it is not typically included as part of a routine health check-up for very young children unless there are specific health concerns.

3. A client states they are taking greater than the recommended daily allowance of vitamin E to prevent cataracts. Which complication should the nurse educate the client as related to taking excessive amounts of vitamin E?

• A. Lung cancer
• B. Stroke
• C. Diarrhea
• D. Liver damage

Correct answer: B

Rationale: The correct answer is B: Stroke. High doses of vitamin E supplements have been associated with an increased risk of hemorrhagic stroke due to its blood-thinning properties. Option A, lung cancer, is not a known complication of excessive vitamin E intake. Option C, diarrhea, is more commonly associated with excessive intake of other vitamins or minerals. Option D, liver damage, is not a commonly reported complication of vitamin E overdose.

4. When doing an initial assessment, the best way for you to identify the client’s priority problem is to:

• A. Interview the client for chief complaints and other symptoms
• B. Talk to the relatives to gather data about history of illness
• C. Do auscultation to check for chest congestion
• D. Do a physical examination while asking the client relevant questions

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. What nursing diagnosis would be most appropriate for a patient with heart failure?

• A. risk for infection
• B. fluid volume excess
• C. impaired body temperature
• D. ineffective airway clearance

Correct answer: B

Rationale: The most appropriate nursing diagnosis for a patient with heart failure is 'fluid volume excess.' In heart failure, the heart's reduced pumping ability leads to fluid retention, causing an excess of fluid in the body. This can result in symptoms such as edema, shortness of breath, and weight gain. 'Risk for infection,' 'impaired body temperature,' and 'ineffective airway clearance' are not the most appropriate nursing diagnoses for a patient with heart failure as they do not directly relate to the pathophysiology and common issues seen in heart failure patients.

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