Nursing Elites

1. The nurse is assessing a client with a new diagnosis of Listeria food poisoning. What action should the nurse take first?

• A. Educate the client on safe food practices.
• B. Start a traceback to identify the source of the outbreak.
• C. Report the case to the county board of health.
• D. Ask the client if they have consumed any unpasteurized products.

Correct answer: D

Rationale: The correct first action for the nurse to take when assessing a client with a new diagnosis of Listeria food poisoning is to inquire if the client has consumed any unpasteurized products. This is crucial because Listeria contamination is often associated with unpasteurized dairy products and undercooked meats. Educating the client on safe food practices (Choice A) is important but not the priority at this initial assessment stage. Starting a traceback to identify the source of the outbreak (Choice B) and reporting the case to the county board of health (Choice C) are necessary actions but should come after gathering information directly from the client regarding potential exposure to high-risk foods.

2. Which type of assessment evaluates a person's risk of malnutrition by ranking key variables from the medical history and physical examination?

• A. Katz index
• B. integrated assessment
• C. subjective global assessment
• D. nutrition care plan

Correct answer: C

Rationale: The Subjective Global Assessment (SGA) is the correct choice. SGA is a comprehensive tool used to assess an individual's risk of malnutrition by integrating key variables from the medical history, physical examination, and other relevant factors. The Katz index is used to assess activities of daily living, not malnutrition risk. An integrated assessment refers to the overall evaluation process involving multiple assessments. A nutrition care plan is a personalized plan developed based on assessment findings, not the assessment itself.

3. You are caring for Conrad who has a brain tumor and increased Intracranial Pressure (ICP). Which intervention should you include in your plan to reduce ICP?

• A. Administer bowel softener
• B. Position Conrad with his head turned toward the side of the tumor
• C. Provide sensory stimulation
• D. Encourage coughing and deep breathing

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.

4. Miss CEE is admitted for treatment of major depression. She appears withdrawn, disheveled, and states 'Nobody wants me'. What does the nurse most likely expect that Miss CEE is to be placed on?

• A. Neuroleptics medication
• B. Special diet
• C. Suicide precaution
• D. Anxiolytics medication

Correct answer: C

Rationale: Given Miss CEE's state of major depression and her expressed feelings of worthlessness ('Nobody wants me'), the nurse would most likely expect her to be placed on suicide precaution. This means that measures would be taken to ensure her safety and to prevent her from harming herself. While medications like neuroleptics (Choice A) and anxiolytics (Choice D) might be employed as part of her overall treatment, these medicines are primarily used for conditions like psychosis and anxiety respectively, not specifically for depression or suicidal ideation. A special diet (Choice B) may be part of a comprehensive treatment plan, but it is not as immediate or as directly related to her current emotional and psychological state as suicide precaution is.

5. Selective inattention is seen in which level of anxiety?

• A. Mild
• B. Moderate
• C. Severe
• D. Panic

Correct answer: D

Rationale: Selective inattention is a defense mechanism seen in panic-level anxiety. In panic anxiety, individuals may experience selective inattention, where they focus only on specific aspects and ignore others. Mild anxiety does not typically involve selective inattention as individuals can still function effectively. Moderate and severe anxiety may impair attention, but selective inattention is more characteristic of panic-level anxiety.

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