Nursing Elites

1. What type of diet is appropriate for a client with chronic cirrhosis?

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

Correct answer: A

Rationale: The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs. Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy. Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein. Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.

2. A client is admitted for observation following an unrestrained motor vehicle accident. A bystander stated that he lost consciousness for 1-2 minutes. On admission, the client's Glasgow Coma Scale (GCS) was 14. The GCS is now 12. The nurse should:

• A. Re-assess in 15 minutes
• B. Stimulate the client with a sternal rub
• C. Administer Tylenol with codeine for a headache
• D. Notify the physician

Correct answer: D

Rationale: A decrease in the Glasgow Coma Scale (GCS) score from 14 to 12 indicates a significant neurological change in the client's condition. This change can be indicative of a deterioration in the client's neurological status, possibly due to intracranial bleeding or swelling. It is crucial for the nurse to notify the physician immediately to ensure prompt evaluation and intervention. Re-assessing in 15 minutes or stimulating the client with a sternal rub are not appropriate actions in this situation as they do not address the underlying cause of the decrease in GCS. Administering Tylenol with codeine for a headache is also not recommended without further assessment and evaluation of the client's condition.

3. The client has been taking divalproex (Depakote) for the management of bipolar disorder. The nurse should give priority to monitoring which laboratory test?

• A. Alanine aminotransferase (ALT)
• B. Serum glucose
• C. Serum creatinine
• D. Serum electrolytes

Correct answer: A

Rationale: The correct answer is Alanine aminotransferase (ALT). Monitoring ALT levels is crucial when a patient is taking divalproex (Depakote) due to the risk of drug-induced hepatitis. Elevated ALT levels indicate liver damage or disorders, which can be a side effect of Depakote. Serum glucose (choice B) is not the priority for monitoring in this case, as the medication does not directly affect glucose levels. Serum creatinine (choice C) is not the most relevant test to monitor for Depakote use; it primarily assesses kidney function. Serum electrolytes (choice D) are important but do not take precedence over monitoring ALT levels when a patient is on Depakote.

4. The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?

• A. Pain management
• B. Airway assessment
• C. Fluid volume status monitoring
• D. Risk for infection prevention

Correct answer: C

Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.

5. Which system is primarily affected by tuberculosis (Mycobacterium)?

• A. stomach (GI)
• B. heart (cardiac)
• C. lungs (respiratory)
• D. skin (integumentary)

Correct answer: C

Rationale: Tuberculosis, caused by Mycobacterium tuberculosis, primarily affects the respiratory system. This aerobic bacillus thrives in highly oxygenated body sites, such as the lungs, growing ends of bones, and the brain. The bacillus is airborne, making the lungs a common site for infection. Choices A, B, and D are incorrect as tuberculosis predominantly impacts the respiratory system and rarely involves the stomach, heart, or skin.

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