Nursing Elites

1. The client with hypertension is being taught about lifestyle changes. Which recommendation is most important to include?

• A. Increase sodium intake
• B. Engage in regular physical activity
• C. Consume a diet high in saturated fats
• D. Limit fluid intake

Correct answer: B

Rationale: Engaging in regular physical activity is crucial for managing hypertension as it helps lower blood pressure. Regular exercise can improve heart health, increase circulation, and contribute to overall well-being, all of which are beneficial for individuals with hypertension. Choice A, increasing sodium intake, is incorrect as reducing sodium is recommended for hypertension to help lower blood pressure. Choice C, consuming a diet high in saturated fats, is incorrect as a diet high in saturated fats can negatively impact blood pressure and cardiovascular health. Choice D, limiting fluid intake, is incorrect as maintaining adequate hydration is important for overall health and not directly related to hypertension management.

2. A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?

• A. Moon face, slow wound healing, muscle wasting, sodium and water retention
• B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
• C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
• D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension

Correct answer: A

Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.

3. The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first?

• A. Place non-skid shoes on the client
• B. Show the client how to use the call light
• C. Use a gait belt to support the client
• D. Assist the client to a bedside sitting position

Correct answer: D

Rationale: To ambulate a client safely after a period of bed rest, the nurse should first assist the client to a bedside sitting position. This initial step ensures the client is stable before attempting to stand and walk, reducing the risk of falls and allowing for a gradual adjustment to activity post-bed rest. Placing non-skid shoes, showing how to use the call light, or using a gait belt are important but should come after ensuring the client is safely seated and stable.

4. A client reports feeling dizzy and light-headed when standing up. What is the nurse's best initial action?

• A. Instruct the client to sit or lie down
• B. Monitor blood pressure and pulse
• C. Administer an anti-dizziness medication
• D. Increase fluid intake

Correct answer: B

Rationale: The correct answer is B: Monitor blood pressure and pulse. When a client reports feeling dizzy and light-headed when standing up, the nurse's best initial action should be to monitor the client's blood pressure and pulse. These symptoms are indicative of orthostatic hypotension, which can be confirmed by changes in blood pressure and pulse when moving from lying to standing positions. Instructing the client to sit or lie down may provide temporary relief but does not address the underlying cause. Administering an anti-dizziness medication should not be the initial action without assessing vital signs first. Increasing fluid intake is important for overall health but is not the priority in this situation where vital sign monitoring is needed to assess for orthostatic hypotension.

5. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department?

• A. Before bedtime, at 2000
• B. After breakfast
• C. Before the evening meal
• D. After lunch

Correct answer: B

Rationale: Scheduling physical exercises after breakfast is the optimal choice for a client with Myasthenia Gravis. This timing allows the client to benefit from renewed energy levels after overnight rest and intake of morning nourishment, enhancing the effectiveness of the therapy session. Choices A (Before bedtime, at 2000) is not suitable as energy levels are likely lower at night, affecting the client's ability to engage effectively in physical exercises. Choices C (Before the evening meal) and D (After lunch) may not be ideal as the client may experience fatigue or weakness later in the day, making it harder to participate actively in therapy.

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