Nursing Elites

1. The nurse interprets the statement “Bow down before me! I am the holy mother of Christ! I am the blessed Virgin Mary!” as important in documenting in which of the following areas of mental status examination?

• A. Thought content
• B. Mood
• C. Affect
• D. Attitude

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

2. A client with nephropathy secondary to diabetes mellitus is receiving dietary teaching from a nurse and plans to make dietary adjustments. Which of the following instructions should the nurse include?

• A. Consume less than 45% of total calories from carbohydrates per day.
• B. Eat no more than 300 mg of cholesterol per day.
• C. Consume less than 0.8 g/kg of body weight of protein per day.
• D. Eat at least 45 g of fiber per day.

Correct answer: D

Rationale: For a client with nephropathy secondary to diabetes mellitus, increasing fiber intake is essential as it can help manage blood sugar levels and improve overall bowel health. Choice A is incorrect because carbohydrates should be controlled but not limited to less than 45% of total calories. Choice B is incorrect as the recommended daily cholesterol intake for individuals with diabetes is less than 200 mg. Choice C is incorrect as protein intake should be individualized based on the client's condition and should not be limited to less than 0.8 g/kg of body weight per day.

3. A nurse is caring for a client who has a new prescription for a low-sodium diet. The client's family has requested to bring in some of the client's favorite foods. Which of the following food items should the nurse tell the family members to omit?

• A. Boiled rice
• B. Flat bread
• C. Broiled fish fillet
• D. Pickled vegetables

Correct answer: D

Rationale: The correct answer is 'Pickled vegetables.' Pickled vegetables are high in sodium due to the pickling process, making them unsuitable for a low-sodium diet. Boiled rice, flat bread, and broiled fish fillet are generally lower in sodium compared to pickled vegetables and can be included in a low-sodium diet. Therefore, the nurse should advise the family to omit pickled vegetables to adhere to the client's dietary restrictions.

4. Which meal should be removed for a client taking warfarin?

• A. Oriental cabbage salad with chicken
• B. Beef enchilada, rice, and beans
• C. Ham and cheese sandwich
• D. Macaroni salad and grapefruit slices

Correct answer: C

Rationale: The correct meal to remove for a client taking warfarin is the 'Ham and cheese sandwich.' Ham is high in vitamin K, which can interfere with the effectiveness of warfarin, a medication that works by decreasing the clotting ability of the blood. Vitamin K can counteract the effects of warfarin by promoting blood clotting. Choices A, B, and D do not contain high amounts of vitamin K and are therefore safer options for individuals taking warfarin.

5. This flip-over card is usually kept in a portable file at the Nurse’s Station. It has 2-parts: the activity and treatment section and a nursing care plan section. This carries information about basic demographic data, primary medical diagnosis, current orders of the physician to be carried out by the nurse, written nursing care plan, nursing orders, scheduled tests and procedures, safety precautions in patient care and factors related to daily living activities. This record is used in the charge-of-shift reports or during the bedside rounds or walking rounds. What record is this?

• A. Discharge Summary
• B. Medicine and Treatment Record
• C. Nursing Health History and Assessment Worksheet
• D. Nursing Kardex

Correct answer: C

Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.

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