Nursing Elites

1. During a health history assessment of a new patient, which data should be the focus for patient teaching?

• A. Age and gender
• B. Saturated fat intake
• C. Hispanic/Latino ethnicity
• D. Family history of diabetes

Correct answer: Saturated fat intake

Rationale: The correct answer is saturated fat intake. Behaviors play a crucial role in health outcomes, and saturated fat intake is a modifiable behavior that can significantly impact a patient's health. By focusing on educating the patient about reducing saturated fat intake, the healthcare provider can empower the patient to make positive changes. While age, gender, ethnicity, and family history are important factors in understanding a patient's health status, they are not behaviors that can be directly modified through patient teaching. Therefore, these factors are essential for developing an individualized care plan but are not the primary focus of patient teaching. Saturated fat intake directly relates to dietary habits, which can be altered through education and support to promote better health outcomes.

2. The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?

• A. Irregular breathing patterns
• B. Minimal heartbeat, dilated pupils
• C. Relaxed muscles, regular breathing, constricted pupils
• D. Euphoria, drowsiness, dizziness

Correct answer: D: Euphoria, drowsiness, dizziness

Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.

3. What question must the nurse ask when formulating a nursing diagnosis?

• A. What diagnosis did the physician make for this client?
• B. What is the issue that I can solve for this client?
• C. What physician orders will resolve this issue?
• D. What underlying disease does this client have?

Correct answer: What is the issue that I can solve for this client?

Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.

4. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

• A. Collect and organize documents for the client's medical record
• B. Prepare the client's identification bracelet
• C. Identify pertinent health history data and current needs and limitations
• D. Gather the client's valuables and secure them in a locked container

Correct answer: Identify pertinent health history data and current needs and limitations

Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.

5. The client is receiving discharge teaching seven (7) days post myocardial infarction and inquires why he must wait six (6) weeks before engaging in sexual intercourse. What is the best response by the nurse to this question?

• A. “You need to regain your strength before attempting such exertion.”
• B. “When you can climb 2 flights of stairs without problems, it is generally safe.”
• C. “Have a glass of wine to relax you, then you can try to have sex.”
• D. “If you can maintain an active walking program, you will have less risk.”

Correct answer: “When you can climb 2 flights of stairs without problems, it is generally safe.”

Rationale: Following a myocardial infarction, there is a risk of cardiac rupture at the site of the infarction for approximately six (6) weeks until scar tissue forms. The advice to wait until the client can climb two flights of stairs without issues is common among healthcare providers as it indicates an adequate level of physical exertion tolerance and suggests a lower risk of complications during sexual activity. Choice A is not specific to the recovery timeline related to sexual activity post-myocardial infarction. Choice C is inappropriate as alcohol consumption should not be recommended before sexual activity. Choice D, though promoting an active lifestyle, does not directly address the safety concerns related to sexual intercourse post-myocardial infarction.

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