Nursing Elites

1. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain?

• A. Balance and coordination
• B. Cognitive status
• C. Level of pain
• D. Upper body muscle strength

Correct answer: D

Rationale: The correct answer is D: Upper body muscle strength. The ability to use a trapeze bar requires adequate upper body strength to support the weight and facilitate repositioning. While assessing pain, coordination, and cognitive status are important, the priority is determining if the client can physically manage the trapeze bar safely. Without sufficient upper body muscle strength, the client may not be able to use the trapeze bar effectively and safely. Assessing balance and coordination is also important but secondary to ensuring the client has the required upper body strength. Cognitive status is crucial for understanding instructions related to using the trapeze bar, but it is not the most critical assessment in this scenario. Pain assessment is essential for overall care but does not directly impact the client's ability to use a trapeze bar like upper body muscle strength does.

2. A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?

• A. Thiamine supplementation
• B. Folic acid replacement
• C. Intravenous glucose
• D. Magnesium sulfate administration

Correct answer: A

Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.

3. A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?

• A. Take the client's temperature and blood pressure.
• B. Encourage the client to rest.
• C. Plan an activity that includes physical exercise.
• D. Carefully observe the client throughout the shift.

Correct answer: D

Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.

4. A client with a fractured femur is placed in skeletal traction. What action should the nurse prioritize?

• A. Ensure that the weights are freely hanging.
• B. Place pillows under the client's knees.
• C. Adjust the weights to alleviate discomfort.
• D. Ensure that the traction ropes are free of knots.

Correct answer: A

Rationale: The correct action the nurse should prioritize when a client is placed in skeletal traction for a fractured femur is to ensure that the weights are freely hanging. This is crucial to maintain proper alignment of the bone and prevent complications. Placing pillows under the client's knees (Choice B) is not a priority in skeletal traction. Adjusting the weights to alleviate discomfort (Choice C) should not be done without proper orders from the healthcare provider. Ensuring that the traction ropes are free of knots (Choice D) is important but ensuring the weights hang freely is the priority to maintain traction effectiveness.

5. What breakfast selection indicates appropriate dietary management for osteoporosis?

• A. Pancakes with syrup and orange juice
• B. Bagel with jelly and skim milk
• C. Eggs with sausage and whole milk
• D. French toast with butter and syrup

Correct answer: B

Rationale: The correct answer is B. A bagel with jelly and skim milk is a calcium-rich and low-fat option that aligns with the dietary recommendations for managing osteoporosis. Osteoporosis is a condition characterized by weak and brittle bones, so it is essential to consume an adequate amount of calcium while avoiding excess fat intake. Choices A, C, and D are not ideal for osteoporosis management as they either lack sufficient calcium, contain high fat content, or both.

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